Provider Demographics
NPI:1235236613
Name:MEDICAL EDUCATION ASSISTANCE CORPORATION UNIVERSITY PHYSICIANS PRACTIC
Entity Type:Organization
Organization Name:MEDICAL EDUCATION ASSISTANCE CORPORATION UNIVERSITY PHYSICIANS PRACTIC
Other - Org Name:EAST TENNESSEE REPRODUCTIVE LABORATORY
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:E
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-433-6050
Mailing Address - Street 1:PO BOX 699
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:TN
Mailing Address - Zip Code:37684-0699
Mailing Address - Country:US
Mailing Address - Phone:423-433-6050
Mailing Address - Fax:423-433-6060
Practice Address - Street 1:VA BLDG 119
Practice Address - Street 2:DOGWOOD LANE
Practice Address - City:MOUNTAIN HOME
Practice Address - State:TN
Practice Address - Zip Code:37684-0699
Practice Address - Country:US
Practice Address - Phone:423-433-6050
Practice Address - Fax:423-433-6060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2147291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN2147OtherSTATE LICENSE
1235200676OtherLAB GROUP NPI
TN3401897Medicare ID - Type Unspecified