Provider Demographics
NPI:1265666747
Name:EAST TENNESSEE PEDIATRIC CARDIOLOGY, P.C.
Entity Type:Organization
Organization Name:EAST TENNESSEE PEDIATRIC CARDIOLOGY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:YVONNE
Authorized Official - Middle Name:A
Authorized Official - Last Name:BREMER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:865-971-6897
Mailing Address - Street 1:2001 LAUREL AVE
Mailing Address - Street 2:SUITE NG4
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37916-1810
Mailing Address - Country:US
Mailing Address - Phone:865-971-6897
Mailing Address - Fax:865-971-1597
Practice Address - Street 1:2001 LAUREL AVE
Practice Address - Street 2:SUITE NG4
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37916-1810
Practice Address - Country:US
Practice Address - Phone:865-971-6897
Practice Address - Fax:865-971-1597
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-12
Last Update Date:2015-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric CardiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100320610Medicaid
TN10370G5623Medicare PIN