Provider Demographics
NPI:1235640467
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:HARDIN VALLEY PEDIATRICS
Other - Org Type:Doing Business As
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:PO BOX 15004
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37901-5004
Mailing Address - Country:US
Mailing Address - Phone:865-541-8895
Mailing Address - Fax:865-633-4808
Practice Address - Street 1:10857 HARDIN VALLEY RD
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37932-1410
Practice Address - Country:US
Practice Address - Phone:865-690-2682
Practice Address - Fax:866-529-5509
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EAST TENNESSEE CHILDREN'S HOSPITAL PRIMARY CARE CENTER, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-10-16
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Multi-Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ035765Medicaid