Healthcare Provider Details

I. General information

NPI: 1013310762
Provider Name (Legal Business Name): KNOXVILLE INTEGRATIVE MEDICAL CENTER PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/08/2014
Last Update Date: 10/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9313 S NORTHSHORE DR
KNOXVILLE TN
37922-6548
US

IV. Provider business mailing address

9313 S NORTHSHORE DR
KNOXVILLE TN
37922-6548
US

V. Phone/Fax

Practice location:
  • Phone: 865-531-6454
  • Fax:
Mailing address:
  • Phone: 865-531-6454
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2302
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number37682
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number24689
License Number StateTN

VIII. Authorized Official

Name: MR. KEVIN STASNEY
Title or Position: OWNER
Credential: M.D.
Phone: 865-531-6454