Healthcare Provider Details

I. General information

NPI: 1184823866
Provider Name (Legal Business Name): ROANE MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2007
Last Update Date: 01/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

814 N KENTUCKY ST
KINGSTON TN
37763-2678
US

IV. Provider business mailing address

814 N KENTUCKY ST
KINGSTON TN
37763-2678
US

V. Phone/Fax

Practice location:
  • Phone: 865-376-6302
  • Fax: 865-376-2989
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberMD00000029236
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPN0000010675
License Number StateTN

VIII. Authorized Official

Name: LAURIE GRAYSON
Title or Position: BILLING CLERK
Credential:
Phone: 865-882-4440