1568570273 NPI number — EAST TENNESSEE STATE UNIVERSITY

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 1568570273 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:
STUDENT UNIVERSITY HEALTH SERVICES
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:
1568570273
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/22/2017
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:
423-439-4515
Provider Business Mailing Address Fax Number:
423-439-5780

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
365 STOUT DRIVE
Provider Second Line Business Practice Location Address:
NICKS HALL RM 160
Provider Business Practice Location Address City Name:
JOHNSON CITY
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37614-6500
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-439-4225
Provider Business Practice Location Address Fax Number:
423-439-4560
Provider Enumeration Date:
08/25/2006

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: 261QM1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 3709292 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com