Provider Demographics
NPI:1609182484
Name:EAST TENNESSEE CLINIC CORP
Entity Type:Organization
Organization Name:EAST TENNESSEE CLINIC CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:PEOPLES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-465-7585
Mailing Address - Street 1:502 W 7TH NORTH ST
Mailing Address - Street 2:
Mailing Address - City:MORRISTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:37814-3957
Mailing Address - Country:US
Mailing Address - Phone:423-586-1818
Mailing Address - Fax:423-586-5989
Practice Address - Street 1:502 W 7TH NORTH ST
Practice Address - Street 2:
Practice Address - City:MORRISTOWN
Practice Address - State:TN
Practice Address - Zip Code:37814-3957
Practice Address - Country:US
Practice Address - Phone:423-586-1818
Practice Address - Fax:423-586-5989
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-31
Last Update Date:2012-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1521155Medicaid
TN103G704895Medicare PIN