Provider Demographics
NPI:1083622526
Name:EAST TENNESSEE NEPHROLOGY PC
Entity Type:Organization
Organization Name:EAST TENNESSEE NEPHROLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT MD
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:C
Authorized Official - Last Name:KISS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:865-524-3131
Mailing Address - Street 1:2001 LAUREL AVE
Mailing Address - Street 2:STE 206
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37916-1865
Mailing Address - Country:US
Mailing Address - Phone:865-524-3131
Mailing Address - Fax:865-212-6323
Practice Address - Street 1:2001 LAUREL AVE
Practice Address - Street 2:STE 206
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37916-1865
Practice Address - Country:US
Practice Address - Phone:865-524-3131
Practice Address - Fax:865-212-6323
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-03
Last Update Date:2010-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3721896Medicaid
TN3721896Medicare ID - Type Unspecified