Provider Demographics
NPI:1407940067
Name:UNICOI COUNTY FAMILY PRACTICE
Entity Type:Organization
Organization Name:UNICOI COUNTY FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OF CORPORATION
Authorized Official - Prefix:DR
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:COLE
Authorized Official - Last Name:CAMPBELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:423-743-8400
Mailing Address - Street 1:P.O. BOX 759
Mailing Address - Street 2:
Mailing Address - City:ERWIN
Mailing Address - State:TN
Mailing Address - Zip Code:37650-0759
Mailing Address - Country:US
Mailing Address - Phone:423-743-8400
Mailing Address - Fax:423-743-6888
Practice Address - Street 1:108 GAY STREET
Practice Address - Street 2:
Practice Address - City:ERWIN
Practice Address - State:TN
Practice Address - Zip Code:37650
Practice Address - Country:US
Practice Address - Phone:423-743-8400
Practice Address - Fax:423-743-6888
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2008-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN25069261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4004557Medicaid
TN4004557Medicaid
TNF82190Medicare UPIN