=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972561066
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MEDICAL EQUIPMENT DISTRIBUTORS OF TENNESSEE, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/01/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 742 W LAMAR ALEXANDER PKWY
-----------------------------------------------------
City | MARYVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37801-3913
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-380-0819
-----------------------------------------------------
Fax | 865-380-0890
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 742 W LAMAR ALEXANDER PKWY
-----------------------------------------------------
City | MARYVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37801-3913
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-380-0819
-----------------------------------------------------
Fax | 865-380-0890
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT
-----------------------------------------------------
Name | MR. JASON JOHN HAMES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 865-380-0819
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | 0000000691
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------