Provider Demographics
NPI:1467581744
Name:EAST TENNESSEE DIALYSIS CENTER INC
Entity Type:Organization
Organization Name:EAST TENNESSEE DIALYSIS CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MOEEN
Authorized Official - Middle Name:A
Authorized Official - Last Name:HATAB
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:865-681-2900
Mailing Address - Street 1:PO BOX 32094
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37930
Mailing Address - Country:US
Mailing Address - Phone:865-681-2900
Mailing Address - Fax:865-980-0907
Practice Address - Street 1:1629 E BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37804-2913
Practice Address - Country:US
Practice Address - Phone:865-681-2900
Practice Address - Fax:865-980-0907
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000124261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0442636Medicaid
442636Medicare ID - Type Unspecified