Healthcare Provider Details

I. General information

NPI: 1104193754
Provider Name (Legal Business Name): ID CONSULTANT PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2011
Last Update Date: 11/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1420 TUSCULUM BLVD
GREENEVILLE TN
37745-4279
US

IV. Provider business mailing address

PO BOX 4015
JOHNSON CITY TN
37602-4015
US

V. Phone/Fax

Practice location:
  • Phone: 423-783-6400
  • Fax: 423-787-5146
Mailing address:
  • Phone: 423-915-1126
  • Fax: 423-915-0635

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: HIREN B PATEL
Title or Position: OWNER
Credential: MD
Phone: 423-943-4030