Healthcare Provider Details

I. General information

NPI: 1114285400
Provider Name (Legal Business Name): TENNESSEE INNOVATIVE MEDICAL SERVICES PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2012
Last Update Date: 07/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 CONCORD RD STE 400
KNOXVILLE TN
37934-2940
US

IV. Provider business mailing address

194 MARKET PLACE BLVD
KNOXVILLE TN
37922-2337
US

V. Phone/Fax

Practice location:
  • Phone: 865-777-6880
  • Fax: 865-777-6881
Mailing address:
  • Phone: 865-560-8787
  • Fax: 865-560-8784

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number StateTN

VIII. Authorized Official

Name: JASON G. FUNDERBURK
Title or Position: SOLE OWNER
Credential: MD
Phone: 865-777-6880