1356379093 NPI number — EMMAUS COMMUNITY HEALTHCARE, PLLC

Table of content: (NPI 1356379093)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356379093 NPI number — EMMAUS COMMUNITY HEALTHCARE, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EMMAUS COMMUNITY HEALTHCARE, PLLC
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:
DBA: PINEY FLATS URGENT CARE
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:
1356379093
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/28/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
509 MEDTECH PKWY
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
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-952-2122
Provider Business Mailing Address Fax Number:
423-952-2145

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6419 BRISTOL HIGHWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PINEY FLATS
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37686
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-538-5202
Provider Business Practice Location Address Fax Number:
423-538-8208
Provider Enumeration Date:
06/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BACKUS
Authorized Official First Name:
CHARLES
Authorized Official Middle Name:
L
Authorized Official Title or Position:
AUTHORIZED OFFICIAL
Authorized Official Telephone Number:
423-538-5202

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QU0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3726460 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: DD0861 . This is a "RR" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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