1033344007 NPI number — EAST TENNESSEE STATE UNIVERSITY

Table of content: (NPI 1033344007)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033344007 NPI number — EAST TENNESSEE STATE UNIVERSITY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAST TENNESSEE STATE UNIVERSITY
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:
Provider Other Organization Name Type Code:
6
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:
1033344007
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/23/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
365 STOUT DRIVE BOX 70403
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:
37614-1703
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-439-4071
Provider Business Mailing Address Fax Number:
423-439-4060

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1440 SUNCREST DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAY
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37615-4118
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-477-1634
Provider Business Practice Location Address Fax Number:
423-477-1625
Provider Enumeration Date:
05/20/2009

Additional Information

Authorized Official

Authorized Official Last Name:
KING
Authorized Official First Name:
BETTY
Authorized Official Middle Name:
J.
Authorized Official Title or Position:
ACTING CHIEF FINANCIAL OFFICER
Authorized Official Telephone Number:
423-439-4414

Provider Taxonomy Codes

  • Taxonomy code: 363LP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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