=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215118088
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TENNESSEE CANCER SPECIALISTS, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/20/2007
-----------------------------------------------------
Last Update Date | 06/16/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 907 E LAMAR ALEXANDER PKWY BLOUNT MEMORIAL HOSPITAL
-----------------------------------------------------
City | MARYVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37804-5015
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-934-5800
-----------------------------------------------------
Fax | 865-934-5801
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 10988
-----------------------------------------------------
City | KNOXVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37939-0988
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-862-0998
-----------------------------------------------------
Fax | 865-544-1861
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF MANAGER/PHYSICIAN
-----------------------------------------------------
Name | MITCHELL D MARTIN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 865-637-9330
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RH0003X
-----------------------------------------------------
Taxonomy Name | Hematology & Oncology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------