Provider Demographics
NPI:1265637441
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:VONORE 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 1:125 MOUNTAIN VIEW DRIVE SUITE 200
Practice Address - Street 2:
Practice Address - City:VONORE
Practice Address - State:TN
Practice Address - Zip Code:37885-2666
Practice Address - Country:US
Practice Address - Phone:423-884-2170
Practice Address - Fax:866-330-9583
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EAST TENNESSEE CHILDREN'S HOSPITAL PRIMARY CARE CENTER INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-06-18
Last Update Date:2023-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Multi-Specialty
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ002814Medicaid