=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316124852
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | URGENT CARE CENTERS OF EAST TENNESSEE, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/28/2008
-----------------------------------------------------
Last Update Date | 05/14/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4021 KEITH ST NW
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37312-4341
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-476-2464
-----------------------------------------------------
Fax | 423-476-1008
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4021 KEITH ST NW
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37312-4341
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-476-2464
-----------------------------------------------------
Fax | 423-478-1008
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. MAHMOOD A SIDDIQUI
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 423-496-9214
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------