Provider Demographics
NPI:1578687372
Name:EAST TENNESSEE PLASTIC SURGERY,P.C.
Entity Type:Organization
Organization Name:EAST TENNESSEE PLASTIC SURGERY,P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:865-694-9886
Mailing Address - Street 1:9430 PARK WEST BLVD STE 240
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37923-4204
Mailing Address - Country:US
Mailing Address - Phone:865-694-9886
Mailing Address - Fax:865-694-5023
Practice Address - Street 1:9430 PARK WEST BLVD STE 240
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37923-4204
Practice Address - Country:US
Practice Address - Phone:865-694-9886
Practice Address - Fax:865-694-5023
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2020-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3113404OtherBCBS
TNB03209Medicare UPIN