Provider Demographics
NPI:1619271608
Name:EAST TN WOMEN'S SPECIALIST
Entity Type:Organization
Organization Name:EAST TN WOMEN'S SPECIALIST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SUSANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:NELMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:865-549-4892
Mailing Address - Street 1:10810 PARKSIDE DR STE 100
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37934-1980
Mailing Address - Country:US
Mailing Address - Phone:865-218-6699
Mailing Address - Fax:
Practice Address - Street 1:10810 PARKSIDE DR STE 100
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37934-1980
Practice Address - Country:US
Practice Address - Phone:865-218-6699
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MERCY PHYSCIAN SERVICES, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-01-05
Last Update Date:2011-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
3373630Medicare PIN