Provider Demographics
NPI:1043503964
Name:MEDICAL INTERACTIVE EDUCATION, LLC
Entity type:Organization
Organization Name:MEDICAL INTERACTIVE EDUCATION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF MEDICAL OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:DOUGHERTY
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:865-599-4409
Mailing Address - Street 1:106 W. SUMMIT HILL DR.
Mailing Address - Street 2:SUITE 301
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37902-1041
Mailing Address - Country:US
Mailing Address - Phone:865-599-4409
Mailing Address - Fax:865-546-5034
Practice Address - Street 1:106 W. SUMMIT HILL DR.
Practice Address - Street 2:SUITE 301
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37902-1041
Practice Address - Country:US
Practice Address - Phone:865-599-4409
Practice Address - Fax:865-546-5034
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-25
Last Update Date:2011-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN83092084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3179569Medicaid
TN3179569Medicaid