=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720172489
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TENNESSEE UROLOGY ASSOCIATES, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/03/2006
-----------------------------------------------------
Last Update Date | 12/17/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9245 PARK WEST BLVD
-----------------------------------------------------
City | KNOXVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37923-4425
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-276-2764
-----------------------------------------------------
Fax | 865-694-7621
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 25 CROSSROADS DR STE 306
-----------------------------------------------------
City | OWINGS MILLS
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21117-5437
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 866-953-3111
-----------------------------------------------------
Fax | 443-471-8540
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING
-----------------------------------------------------
Name | MARY LAUTERBACH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 443-738-2889
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332900000X
-----------------------------------------------------
Taxonomy Name | Non-Pharmacy Dispensing Site
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------