Healthcare Provider Details

I. General information

NPI: 1063507572
Provider Name (Legal Business Name): CORNELIUS J. MANCE, M.D., P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2051 B HAMILL ROAD
HIXSON TN
37343
US

IV. Provider business mailing address

5309 INLET VIEW LANE
HIXSON TN
37343
US

V. Phone/Fax

Practice location:
  • Phone: 423-877-1212
  • Fax:
Mailing address:
  • Phone: 423-954-9556
  • Fax: 423-954-9505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier3046304
Identifier TypeMEDICAID
Identifier StateTN
Identifier Issuer
# 2
Identifier3074846
Identifier TypeOTHER
Identifier StateTN
Identifier IssuerBLUECROSS/BLUESHIELD

VIII. Authorized Official

Name: DR. CORNELIUS JEFFERSON MANCE
Title or Position: PRESIDENT
Credential: M.D.
Phone: 423-954-9556