Provider Demographics
NPI:1043322415
Name:SURGICAL GROUP OF NORTHEAST TENNESSEE
Entity Type:Organization
Organization Name:SURGICAL GROUP OF NORTHEAST TENNESSEE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:JOHNSON
Authorized Official - Last Name:FORE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:423-743-4151
Mailing Address - Street 1:361 OKOLONA DR
Mailing Address - Street 2:
Mailing Address - City:ERWIN
Mailing Address - State:TN
Mailing Address - Zip Code:37650-2183
Mailing Address - Country:US
Mailing Address - Phone:423-743-4151
Mailing Address - Fax:423-743-7580
Practice Address - Street 1:361 OKOLONA DR
Practice Address - Street 2:
Practice Address - City:ERWIN
Practice Address - State:TN
Practice Address - Zip Code:37650-2183
Practice Address - Country:US
Practice Address - Phone:423-743-4151
Practice Address - Fax:423-743-7580
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000026800208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3700364Medicaid
TNG75875Medicare UPIN
TN3700364Medicaid