Provider Demographics
NPI:1366452914
Name:EAST TENNESSEE BRAIN & SPINE CENTER, PC
Entity Type:Organization
Organization Name:EAST TENNESSEE BRAIN & SPINE CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:A
Authorized Official - Last Name:WILES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:423-232-8301
Mailing Address - Street 1:PO BOX 9150
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42002-9150
Mailing Address - Country:US
Mailing Address - Phone:270-744-9600
Mailing Address - Fax:270-744-0834
Practice Address - Street 1:701 MED TECH PKWY
Practice Address - Street 2:SUITE 300
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-2365
Practice Address - Country:US
Practice Address - Phone:423-232-8301
Practice Address - Fax:423-232-8304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-08
Last Update Date:2012-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN207T00000X, 363AS0400X
363LA2200X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Multi-Specialty
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4069221OtherBLUE CROSS/BLUE SHIELD
TN3721061Medicaid
VA1366452914Medicaid
NC5903904Medicaid
KY7100132610Medicaid
TN4069221OtherBLUE CROSS/BLUE SHIELD
NC5903904Medicaid
TNCH8343Medicare PIN