1235640467 NPI number — EAST TENNESSEE CHILDREN'S HOSPITAL PRIMARY CARE CENTER, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235640467 NPI number — EAST TENNESSEE CHILDREN'S HOSPITAL PRIMARY CARE CENTER, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAST TENNESSEE CHILDREN'S HOSPITAL PRIMARY CARE CENTER, INC.
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:
1235640467
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/08/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 15004
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KNOXVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37901-5004
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
865-541-8895
Provider Business Mailing Address Fax Number:
865-633-4808

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10857 HARDIN VALLEY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KNOXVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37932-1410
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
865-690-2682
Provider Business Practice Location Address Fax Number:
866-529-5509
Provider Enumeration Date:
10/16/2017

Additional Information

Authorized Official

Authorized Official Last Name:
HAWTHORNE
Authorized Official First Name:
CARYN
Authorized Official Middle Name:
Authorized Official Title or Position:
VICE PRESIDENT FINANCE
Authorized Official Telephone Number:
865-541-8181

Provider Taxonomy Codes

  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: Q035765 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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