Healthcare Provider Details

I. General information

NPI: 1093202137
Provider Name (Legal Business Name): MDCONNECT HEALTHCARE CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2018
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1612 DOWNTOWN WEST BLVD
KNOXVILLE TN
37919-5408
US

IV. Provider business mailing address

11161 E STATE ROAD 70 UNIT 110
LAKEWOOD RANCH FL
34202-9407
US

V. Phone/Fax

Practice location:
  • Phone: 800-926-3047
  • Fax: 941-296-8588
Mailing address:
  • Phone: 800-926-3047
  • Fax: 941-296-8588

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code247ZC0005X
TaxonomyClinical Laboratory Director (Non-physician)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: BRADLEY SCOTT GREVIOUS
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 941-914-8286