Provider Demographics
NPI:1629073630
Name:ERWIN MEDICAL CLINIC
Entity Type:Organization
Organization Name:ERWIN MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN ASSISTANT
Authorized Official - Prefix:MR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:
Authorized Official - Last Name:DIXON
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C, MBA
Authorized Official - Phone:423-743-9994
Mailing Address - Street 1:3101 BROWNS MILL RD
Mailing Address - Street 2:STE 6-222
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-4100
Mailing Address - Country:US
Mailing Address - Phone:423-743-9994
Mailing Address - Fax:423-743-9995
Practice Address - Street 1:1201 N MAIN AVE
Practice Address - Street 2:STE 3
Practice Address - City:ERWIN
Practice Address - State:TN
Practice Address - Zip Code:37650-9168
Practice Address - Country:US
Practice Address - Phone:423-743-9994
Practice Address - Fax:423-743-9995
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN00000187261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3666061Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER