Healthcare Provider Details

I. General information

NPI: 1245752997
Provider Name (Legal Business Name): FAMILY PRACTICE OF CORRYTON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2017
Last Update Date: 07/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7701 CORRYTON RD
CORRYTON TN
37721-2630
US

IV. Provider business mailing address

PO BOX 88
CORRYTON TN
37721-0088
US

V. Phone/Fax

Practice location:
  • Phone: 865-247-6263
  • Fax: 865-992-8103
Mailing address:
  • Phone: 865-992-3031
  • Fax: 865-992-8103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: KIM M DAUGHERTY
Title or Position: OFFICE MANAGER
Credential:
Phone: 865-992-3031