Healthcare Provider Details

I. General information

NPI: 1356788202
Provider Name (Legal Business Name): PHILIP HENRY HANNEMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2013
Last Update Date: 06/26/2020
Certification Date: 06/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

463 BMH PHYSICIANS OFFICE BLDG
MARYVILLE TN
37804-5807
US

IV. Provider business mailing address

103 W BROADWAY AVE
MARYVILLE TN
37801-4703
US

V. Phone/Fax

Practice location:
  • Phone: 865-980-5100
  • Fax: 865-980-5105
Mailing address:
  • Phone: 865-273-1752
  • Fax: 865-273-1755

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number61011
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number61011
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: