Healthcare Provider Details

I. General information

NPI: 1346283553
Provider Name (Legal Business Name): BLAINE L. ENDERSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 09/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1924 ALCOA HWY U114
KNOXVILLE TN
37920-1511
US

IV. Provider business mailing address

PO BOX 440473
NASHVILLE TN
37244-0473
US

V. Phone/Fax

Practice location:
  • Phone: 865-305-9340
  • Fax: 865-305-9231
Mailing address:
  • Phone: 865-670-6199
  • Fax: 865-670-6188

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License NumberMD0000018190
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: