Provider Demographics
NPI:1477660199
Name:EAST TENNESSEE STATE UNIVERSITY
Entity Type:Organization
Organization Name:EAST TENNESSEE STATE UNIVERSITY
Other - Org Name:JOHNSON CITY COMMUNITY HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR ASSOCIATE VICE PRESIDENT F&A
Authorized Official - Prefix:
Authorized Official - First Name:BETTY
Authorized Official - Middle Name:J
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-439-4414
Mailing Address - Street 1:365 STOUT DRIVE, BOX 70403
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37614-1703
Mailing Address - Country:US
Mailing Address - Phone:423-439-4515
Mailing Address - Fax:423-439-5780
Practice Address - Street 1:2151 CENTURY LANE
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604
Practice Address - Country:US
Practice Address - Phone:423-926-2500
Practice Address - Fax:423-926-5999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0441901Medicaid
441901Medicare Oscar/Certification
3709292Medicare PIN