Provider Demographics
NPI:1609988930
Name:KINGSPORT ANESTHESIA, PLC
Entity Type:Organization
Organization Name:KINGSPORT ANESTHESIA, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LORNA
Authorized Official - Middle Name:K
Authorized Official - Last Name:EHRENFRIED
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:423-854-0001
Mailing Address - Street 1:3101 BROWNS MILL RD STE 6 PMB 386
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-4100
Mailing Address - Country:US
Mailing Address - Phone:423-854-0001
Mailing Address - Fax:423-854-0002
Practice Address - Street 1:302 WESLEY ST STE 3
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601-1741
Practice Address - Country:US
Practice Address - Phone:423-283-7302
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000034445174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3856308Medicaid
TN4067843OtherBCBS TN PROVIDER NUMBER
TN3856308Medicaid
TNG73679Medicare UPIN