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General NPI Number Information
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NPI Number | 1740534049
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Entity Type | Organization
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Legal Business Name | PRODIGAL PRIMARY CARE PC
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Dates
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Enumeration Date | 11/08/2012
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Last Update Date | 11/01/2013
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Provider Practice Location Address
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Address Line | 901 MERCHANT DR
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City | KNOXVILLE
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State | TN
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Zip | 37912-3862
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Country | US
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Telephone | 865-474-1053
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Fax | 865-951-2401
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Provider Business Mailing Address
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Address Line | 2911 ESSARY DR
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City | KNOXVILLE
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State | TN
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Zip | 37918-2468
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Country | US
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Telephone | 865-288-3754
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Fax | 865-243-2250
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Authorized Official
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Title or Position | PA
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Name | MR. DAVID E BRICKHOUSE
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Credential | PA
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Telephone | 865-288-3754
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number |
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License Number State |
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