Provider Demographics
NPI:1649442237
Name:BISHOFBERGER MEDICAL ASSOCIATES OF EAST TENNESSEE
Entity type:Organization
Organization Name:BISHOFBERGER MEDICAL ASSOCIATES OF EAST TENNESSEE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:E
Authorized Official - Last Name:BISHOFBERGER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:423-784-1300
Mailing Address - Street 1:1381 RELIABLE PKWY
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60686-0013
Mailing Address - Country:US
Mailing Address - Phone:317-216-2528
Mailing Address - Fax:317-216-2894
Practice Address - Street 1:188 HOSPITAL LN
Practice Address - Street 2:
Practice Address - City:JELLICO
Practice Address - State:TN
Practice Address - Zip Code:37762-4400
Practice Address - Country:US
Practice Address - Phone:423-784-1300
Practice Address - Fax:423-784-1420
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-24
Last Update Date:2011-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN41757208600000X, 261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1174681639OtherMEDICARE RAILROAD CARRIER -GROUP MEMBER NPI
DQ1434OtherMEDICARE RAILROAD CARRIER -GROUP PTAN
P00817876OtherMEDICARE RAILROAD CARRIER -GROUP MEMBER PTAN
1649442237OtherMEDICARE RAILROAD CARRIER -GROUP NPI
TN41757OtherTN LICENSURE
TN4177360OtherBLUECROSS BLUESHIELD OF TENN
TN38328132Medicare PIN