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? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 213ES0103X | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | Group - Single Specialty |