MEDICARE: TENNESSEE RIVER PHYSICIANS, PLLC

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	207P00000X	Emergency Medicine Physician

General Provider Information

NPI Number	:	1528505690
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TENNESSEE RIVER PHYSICIANS, PLLC

Provider Business Mailing Address
First Line	:	PO BOX 20882
Second Line	:
City	:	BELFAST
State	:	ME
Zip	:	04915-4105
Country	:	US
Telephone Number	:	770-874-5400
Fax Number	:

Provider Business Practice Location Address
First Line	:	632 MORRISON SPRINGS RD
Second Line	:
City	:	CHATTANOOGA
State	:	TN
Zip	:	37415-3402
Country	:	US
Telephone Number	:	423-778-3393
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF CREDENTIALING
Name	:	KIM H LARSEN
Credential	:
Telephone Number	:	770-874-5400

Provider Enumeration Date	:	01/26/2017
Last Update Date	:	02/05/2020

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