Provider Demographics
NPI:1679126056
Name:EAST TENNESSEE CHILDREN'S HOSPITAL ASSOCIATION INC.
Entity Type:Organization
Organization Name:EAST TENNESSEE CHILDREN'S HOSPITAL ASSOCIATION INC.
Other - Org Name:KNOXVILLE PEDIATRIC CARDIOLOGY -MORRISTOWN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:B
Authorized Official - Last Name:MASON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:865-541-8053
Mailing Address - Street 1:PO BOX 15004
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37901-5004
Mailing Address - Country:US
Mailing Address - Phone:865-541-8895
Mailing Address - Fax:865-633-4808
Practice Address - Street 1:1817 W MORRIS BLVD
Practice Address - Street 2:
Practice Address - City:MORRISTOWN
Practice Address - State:TN
Practice Address - Zip Code:37813-2837
Practice Address - Country:US
Practice Address - Phone:865-522-0420
Practice Address - Fax:877-801-6771
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EAST TENNESSEE CHILDREN'S HOSPITAL ASSOCIATION INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-07-24
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric CardiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ050605Medicaid