1508134768 NPI number — EAST TENNESSEE HEMATOLOGY-ONCOLOGY ASSOC

Table of content: (NPI 1508134768)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508134768 NPI number — EAST TENNESSEE HEMATOLOGY-ONCOLOGY ASSOC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAST TENNESSEE HEMATOLOGY-ONCOLOGY ASSOC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MCLEOD CANCER AND BLOOD CENTER PHARMACY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1508134768
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/02/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
310 N STATE OF FRANKLIN RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JOHNSON CITY
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37604-6008
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-926-3611
Provider Business Mailing Address Fax Number:
423-926-3073

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
302 WESLEY ST STE 3
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JOHNSON CITY
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37601-1741
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-631-0523
Provider Business Practice Location Address Fax Number:
423-631-0522
Provider Enumeration Date:
12/02/2011

Additional Information

Authorized Official

Authorized Official Last Name:
COMBS
Authorized Official First Name:
MIKE
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
423-461-7867

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  4926 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 4444674 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".




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