Provider Demographics
NPI:1619089034
Name:EAST TENNESSEE MEDICAL ASSOCIATES, P.C.
Entity Type:Organization
Organization Name:EAST TENNESSEE MEDICAL ASSOCIATES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE-PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STANLEY
Authorized Official - Middle Name:E
Authorized Official - Last Name:VERMILLION
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:423-929-7158
Mailing Address - Street 1:107 WOODLAWN DR
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-5978
Mailing Address - Country:US
Mailing Address - Phone:423-929-7158
Mailing Address - Fax:423-928-9625
Practice Address - Street 1:107 WOODLAWN DR
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-5978
Practice Address - Country:US
Practice Address - Phone:423-929-7158
Practice Address - Fax:423-928-9625
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2010-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD6775207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3378504Medicare PIN