Provider Demographics
NPI:1750427175
Name:STATE OF TENNESSEE
Entity type:Organization
Organization Name:STATE OF TENNESSEE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ACCOUNTANT
Authorized Official - Prefix:MS
Authorized Official - First Name:KIMBERLI
Authorized Official - Middle Name:LENISE
Authorized Official - Last Name:FITZPATRICK
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:423-979-3200
Mailing Address - Street 1:101 OKOLONA DR
Mailing Address - Street 2:
Mailing Address - City:ERWIN
Mailing Address - State:TN
Mailing Address - Zip Code:37650-1387
Mailing Address - Country:US
Mailing Address - Phone:423-743-9103
Mailing Address - Fax:
Practice Address - Street 1:101 OKOLONA DR
Practice Address - Street 2:
Practice Address - City:ERWIN
Practice Address - State:TN
Practice Address - Zip Code:37650-1387
Practice Address - Country:US
Practice Address - Phone:423-979-3200
Practice Address - Fax:423-979-3271
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2012-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3910519Medicare PIN