=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184823866
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROANE MEDICAL CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/13/2007
-----------------------------------------------------
Last Update Date | 01/17/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 814 N KENTUCKY ST
-----------------------------------------------------
City | KINGSTON
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37763-2678
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-376-6302
-----------------------------------------------------
Fax | 865-376-2989
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 814 N KENTUCKY ST
-----------------------------------------------------
City | KINGSTON
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37763-2678
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLING CLERK
-----------------------------------------------------
Name | LAURIE GRAYSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 865-882-4440
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | APN0000010675
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | MD00000029236
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------