Provider Demographics
NPI:1417031071
Name:SMOKIE MOUNTAIN DIALYSIS INC.
Entity Type:Organization
Organization Name:SMOKIE MOUNTAIN DIALYSIS INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STANLEY
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:VERMILLION
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:423-232-8882
Mailing Address - Street 1:PO BOX 4087
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37602-4087
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 MED TECH PKWY
Practice Address - Street 2:SUITE 406
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-4007
Practice Address - Country:US
Practice Address - Phone:423-232-8882
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2011-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4146761Medicaid
GA442668Medicare Oscar/Certification