=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144008236
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TENNESSEE CANCER SPECIALIST PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/19/2023
-----------------------------------------------------
Last Update Date | 09/19/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 120 HOSPITAL DR STE 100
-----------------------------------------------------
City | JEFFERSON CITY
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37760-5204
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-934-5800
-----------------------------------------------------
Fax | 865-934-5801
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 900 E HILL AVE STE 230
-----------------------------------------------------
City | KNOXVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37915-2565
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-862-0998
-----------------------------------------------------
Fax | 865-544-1861
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING COORDINATOR
-----------------------------------------------------
Name | PATRICIA G JENKINS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 865-257-0855
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RH0003X
-----------------------------------------------------
Taxonomy Name | Hematology & Oncology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------