1871361436 NPI number — EAST TENNESSEE ADDICTION SPECIALISTS

Table of content: (NPI 1871361436)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871361436 NPI number — EAST TENNESSEE ADDICTION SPECIALISTS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAST TENNESSEE ADDICTION SPECIALISTS
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:
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:
1871361436
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/23/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2036 CHILHOWEE MEDICAL PARK
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARYVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37804-5285
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
865-268-4360
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20445 ALBERTA ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ONEIDA
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37841-3509
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-286-7638
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/13/2023

Additional Information

Authorized Official

Authorized Official Last Name:
STALCUP
Authorized Official First Name:
CLAY
Authorized Official Middle Name:
EUGENE
Authorized Official Title or Position:
CO-OWNER
Authorized Official Telephone Number:
865-406-2715

Provider Taxonomy Codes

  • Taxonomy code: 261QR0405X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: Q045176 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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