1225214307 NPI number — ELMER G. PINZON

Table of content: (NPI 1225214307)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225214307 NPI number — ELMER G. PINZON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ELMER G. PINZON
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1225214307
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/22/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 63141
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28263-3141
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
865-670-6199
Provider Business Mailing Address Fax Number:
865-670-6188

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
110 CENTER PARK DR
Provider Second Line Business Practice Location Address:
STE 102 & 103
Provider Business Practice Location Address City Name:
KNOXVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37922-2114
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
865-690-3737
Provider Business Practice Location Address Fax Number:
865-690-3757
Provider Enumeration Date:
01/18/2008

Additional Information

Authorized Official

Authorized Official Last Name:
PINZON
Authorized Official First Name:
ELMER
Authorized Official Middle Name:
G
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
865-690-3737

Provider Taxonomy Codes

  • Taxonomy code: 2081P2900X , with the licence number:  MD 35871 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 38717082 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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