Healthcare Provider Details

I. General information

NPI: 1255750261
Provider Name (Legal Business Name): CHATTANOOGA PRIMARY CARE OF HYPERTENSION & DIABETES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/08/2014
Last Update Date: 04/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5600 BRAINERD RD STE FC-5
CHATTANOOGA TN
37411-5310
US

IV. Provider business mailing address

5600 BRAINERD RD STE FC-5
CHATTANOOGA TN
37411-5310
US

V. Phone/Fax

Practice location:
  • Phone: 423-355-5471
  • Fax: 423-355-5472
Mailing address:
  • Phone: 423-355-5471
  • Fax: 423-355-5472

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number21478
License Number StateTN

VIII. Authorized Official

Name: DR. KAVIN J JOHNSON
Title or Position: OWNER
Credential: MD
Phone: 423-309-6437