Provider Demographics
NPI:1164488219
Name:ENDOSCOPY CENTER OF NORTHEAST TENNESSEE, PC
Entity Type:Organization
Organization Name:ENDOSCOPY CENTER OF NORTHEAST TENNESSEE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FACILITY ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:PENNY
Authorized Official - Middle Name:B
Authorized Official - Last Name:RUTLEDGE
Authorized Official - Suffix:
Authorized Official - Credentials:FACMPE, MPH
Authorized Official - Phone:423-929-7111
Mailing Address - Street 1:310 N STATE OF FRANKLIN RD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-6008
Mailing Address - Country:US
Mailing Address - Phone:423-929-7111
Mailing Address - Fax:423-929-9448
Practice Address - Street 1:310 N STATE OF FRANKLIN RD
Practice Address - Street 2:SUITE 202
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-6008
Practice Address - Country:US
Practice Address - Phone:423-929-7111
Practice Address - Fax:423-929-9448
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000056261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3287479Medicaid
TN3287479Medicaid