MEDICARE: STATE OF TENNESSEE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251K00000X	Public Health or Welfare Agency		TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1447397666
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STATE OF TENNESSEE

Provider Business Mailing Address
First Line	:	219 PRINCETON RD
Second Line	:
City	:	JOHNSON CITY
State	:	TN
Zip	:	37601-2062
Country	:	US
Telephone Number	:	423-975-2200
Fax Number	:	423-975-2210

Provider Business Practice Location Address
First Line	:	219 PRINCETON RD
Second Line	:
City	:	JOHNSON CITY
State	:	TN
Zip	:	37601-2062
Country	:	US
Telephone Number	:	423-979-4609
Fax Number	:	423-979-3271

Authorized Official
Title or Position	:	COUNTY DIRECTOR 3
Name	:	MR. JAMES TIMOTHY CARSON
Credential	:	MSEH
Telephone Number	:	423-975-7927

Provider Enumeration Date	:	01/30/2007
Last Update Date	:	07/21/2022

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Directions to “STATE OF TENNESSEE ” Practice Location

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