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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0156761	OTHER	TN	BC/BS & TENNCARE SELECT
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1902827363
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STATE OF TENNESSEE

Provider Business Mailing Address
First Line	:	102 J V MANGUBAT DR
Second Line	:
City	:	WAYNESBORO
State	:	TN
Zip	:	38485-2439
Country	:	US
Telephone Number	:	931-722-3292
Fax Number	:	931-722-7249

Provider Business Practice Location Address
First Line	:	102 J V MANGUBAT DR
Second Line	:
City	:	WAYNESBORO
State	:	TN
Zip	:	38485-2439
Country	:	US
Telephone Number	:	931-722-3292
Fax Number	:	931-722-7249

Authorized Official
Title or Position	:	OFFICE SUPERVISOR
Name	:	BARBARA J WHITWELL
Credential	:
Telephone Number	:	931-490-8334

Provider Enumeration Date	:	07/21/2006
Last Update Date	:	09/25/2012

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Directions to “STATE OF TENNESSEE ” Practice Location

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