Healthcare Provider Details

I. General information

NPI: 1063762649
Provider Name (Legal Business Name): PRODIGAL PRIMARY CARE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2012
Last Update Date: 11/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2911 ESSARY ROAD
KNOXVILLE TN
37918-2468
US

IV. Provider business mailing address

2911 ESSARY ROAD
KNOXVILLE TN
37918-2468
US

V. Phone/Fax

Practice location:
  • Phone: 865-288-3757
  • Fax: 865-243-2250
Mailing address:
  • Phone: 865-288-3757
  • Fax: 865-243-2250

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: DAVID E BRICKHOUSE
Title or Position: OWNER
Credential: PA-C
Phone: 865-288-3754