Provider Demographics
NPI:1487791315
Name:STATE OF TENNESSEE
Entity type:Organization
Organization Name:STATE OF TENNESSEE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ACCOUNTING MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:MCCARTHY
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:423-634-5832
Mailing Address - Street 1:24 E 7TH ST
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:TN
Mailing Address - Zip Code:37347-3301
Mailing Address - Country:US
Mailing Address - Phone:423-942-2238
Mailing Address - Fax:423-942-9186
Practice Address - Street 1:24 E 7TH ST
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:TN
Practice Address - Zip Code:37347-3301
Practice Address - Country:US
Practice Address - Phone:423-942-2238
Practice Address - Fax:423-942-9186
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3911004Medicare ID - Type UnspecifiedFLU PROVIDER NUMBER