Provider Demographics
NPI:1508879719
Name:EAST TENNESSEE VASCULAR CENTER, PLLC
Entity Type:Organization
Organization Name:EAST TENNESSEE VASCULAR CENTER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:SHAHIN
Authorized Official - Middle Name:
Authorized Official - Last Name:ASSADNIA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:423-317-6560
Mailing Address - Street 1:PO BOX 1855
Mailing Address - Street 2:
Mailing Address - City:MORRISTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:37816-1855
Mailing Address - Country:US
Mailing Address - Phone:423-317-6560
Mailing Address - Fax:423-317-6570
Practice Address - Street 1:1125 W 1ST NORTH ST
Practice Address - Street 2:STE. B
Practice Address - City:MORRISTOWN
Practice Address - State:TN
Practice Address - Zip Code:37814-4562
Practice Address - Country:US
Practice Address - Phone:423-317-6560
Practice Address - Fax:423-317-6570
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-15
Last Update Date:2011-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD358812086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1114909538OtherINDIVIDUAL NPI
TN3723200Medicaid
TN1639178932OtherINDIVIDUAL NPI
TN4075540OtherBLUE CROSS BLUE SHIELD
TNP00122001OtherRAILROAD MEDICARE
TNP00122001OtherRAILROAD MEDICARE