Provider Demographics
NPI:1609388438
Name:EAST TENNESSEE CHILDREN'S HOSPITAL ASSOCIATION, INC.
Entity Type:Organization
Organization Name:EAST TENNESSEE CHILDREN'S HOSPITAL ASSOCIATION, INC.
Other - Org Name:KNOXVILLE PEDIATRIC CARDIOLOGY-CLEVELAND
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REGIONAL PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:B
Authorized Official - Last Name:MASON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:865-541-8053
Mailing Address - Street 1:PO BOX 15004
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37901-5004
Mailing Address - Country:US
Mailing Address - Phone:865-541-8895
Mailing Address - Fax:865-633-4808
Practice Address - Street 1:1060 PEERLESS XING NW STE 100
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37312-3785
Practice Address - Country:US
Practice Address - Phone:865-522-0420
Practice Address - Fax:877-801-6771
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EAST TENNESSEE CHILDREN'S HOSPITAL ASSOCIATION, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-11-02
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric CardiologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical SpecialtyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ035981Medicaid