Provider Demographics
NPI:1053620765
Name:MARYVILLE PULMONARY & SLEEP MEDICINE, LLC
Entity type:Organization
Organization Name:MARYVILLE PULMONARY & SLEEP MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JABER
Authorized Official - Middle Name:M
Authorized Official - Last Name:MONLA-HASSAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:865-980-5100
Mailing Address - Street 1:PO BOX 5659
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37802-5659
Mailing Address - Country:US
Mailing Address - Phone:865-273-1752
Mailing Address - Fax:865-273-1755
Practice Address - Street 1:5401 OLD YORK ROAD
Practice Address - Street 2:KLEIN-SUITE 300
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19141-3030
Practice Address - Country:US
Practice Address - Phone:215-456-6950
Practice Address - Fax:215-456-1766
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN38341207RP1001X, 207RS0012X
PAMD433403207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1520768Medicaid
TN103G702499Medicare PIN