Healthcare Provider Details

I. General information

NPI: 1407834211
Provider Name (Legal Business Name): CHADI MILAD JARJOURA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2006
Last Update Date: 07/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 W PARK DR
KINGSPORT TN
37660-3805
US

IV. Provider business mailing address

105 W PARK DR
KINGSPORT TN
37660-3805
US

V. Phone/Fax

Practice location:
  • Phone: 423-224-3220
  • Fax: 423-224-3233
Mailing address:
  • Phone: 423-224-3220
  • Fax: 423-224-3233

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberME91543
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number0101241983
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License NumberMD40762
License Number StateTN
# 4
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberMD40762
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: