Provider Demographics
NPI:1659462422
Name:ORTHOTENNESSEE, PC
Entity Type:Organization
Organization Name:ORTHOTENNESSEE, PC
Other - Org Name:LAKEWAY ORTHOPAEDIC CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JON-DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:DEESON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:865-769-4545
Mailing Address - Street 1:460 MEDICAL PARK DR
Mailing Address - Street 2:SUITE 104
Mailing Address - City:LENOIR CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37772-5640
Mailing Address - Country:US
Mailing Address - Phone:865-986-7737
Mailing Address - Fax:865-986-7807
Practice Address - Street 1:460 MEDICAL PARK DR
Practice Address - Street 2:SUITE 104
Practice Address - City:LENOIR CITY
Practice Address - State:TN
Practice Address - Zip Code:37772-5640
Practice Address - Country:US
Practice Address - Phone:865-986-7737
Practice Address - Fax:865-986-7807
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2017-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3711621Medicare ID - Type Unspecified