=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033155965
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TRI-STATE RADIOLOGY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/20/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1850 OLD KNOXVILLE RD
-----------------------------------------------------
City | TAZEWELL
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37879-3625
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-626-4211
-----------------------------------------------------
Fax | 606-248-1320
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 596
-----------------------------------------------------
City | TAZEWELL
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37879-0596
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-248-1320
-----------------------------------------------------
Fax | 606-248-1518
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | SUNAN VONGKASEMSIRI
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 606-248-1320
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | MD0000014904
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------