Provider Demographics
NPI:1235350901
Name:EAST TENNESSEE CHILDREN'S HOSPITAL PRIMARY CARE CENTER, INC.
Entity Type:Organization
Organization Name:EAST TENNESSEE CHILDREN'S HOSPITAL PRIMARY CARE CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:CARYN
Authorized Official - Middle Name:
Authorized Official - Last Name:HAWTHORNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:865-541-8181
Mailing Address - Street 1:P.O. BOX 15004
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37901
Mailing Address - Country:US
Mailing Address - Phone:865-541-8895
Mailing Address - Fax:865-633-4808
Practice Address - Street 1:2018 CLINCH AVE
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37916-2301
Practice Address - Country:US
Practice Address - Phone:865-541-8000
Practice Address - Fax:865-633-4808
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EAST TENNESSEE CHILDREN'S HOSPITAL PRIMARY CARE CENTER INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-01
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
208000000X, 363LF0000X, 363LP0200X
TN261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical SpecialtyGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ038603Medicaid