Provider Demographics
NPI:1619525961
Name:PODIATRIC CLINICS OF NORTHEAST TN
Entity Type:Organization
Organization Name:PODIATRIC CLINICS OF NORTHEAST TN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSOCIATE
Authorized Official - Prefix:
Authorized Official - First Name:SALLEE
Authorized Official - Middle Name:
Authorized Official - Last Name:RANDOLPH
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:423-232-1771
Mailing Address - Street 1:1303 SUNSET DR STE 6
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-7905
Mailing Address - Country:US
Mailing Address - Phone:423-232-1771
Mailing Address - Fax:423-929-0328
Practice Address - Street 1:1303 SUNSET DR STE 6
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-7905
Practice Address - Country:US
Practice Address - Phone:423-232-1771
Practice Address - Fax:423-929-0328
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-29
Last Update Date:2019-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty