Healthcare Provider Details

I. General information

NPI: 1801892054
Provider Name (Legal Business Name): MARK JOSEPH DALLE-AVE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2005
Last Update Date: 02/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4307 HIGHWAY 66 S
ROGERSVILLE TN
37857-3155
US

IV. Provider business mailing address

PO BOX 850
ROGERSVILLE TN
37857-0850
US

V. Phone/Fax

Practice location:
  • Phone: 423-921-1600
  • Fax: 423-921-1677
Mailing address:
  • Phone: 423-272-5202
  • Fax: 423-272-4696

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25875
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: