=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336199645
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARYVILLE ANESTHESIOLOGISTS PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/10/2006
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 907 E LAMAR ALEXANDER PKWY
-----------------------------------------------------
City | MARYVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37804-5015
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-983-7211
-----------------------------------------------------
Fax | 855-917-2023
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 3181
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46206-3181
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 855-381-0344
-----------------------------------------------------
Fax | 800-731-0751
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | CHERYL E COLEMAN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 865-983-7211
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------