Provider Demographics
NPI:1710936257
Name:EAST TENNESSEE UROLOGIC ASSOCIATES
Entity Type:Organization
Organization Name:EAST TENNESSEE UROLOGIC ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:KAY
Authorized Official - Middle Name:D
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-928-0168
Mailing Address - Street 1:508 PRINCETON RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-2060
Mailing Address - Country:US
Mailing Address - Phone:423-928-0168
Mailing Address - Fax:423-928-5141
Practice Address - Street 1:508 PRINCETON RD
Practice Address - Street 2:SUITE 104
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601-2060
Practice Address - Country:US
Practice Address - Phone:423-928-0168
Practice Address - Fax:423-928-5141
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNCF2875OtherRAILROAD MEDICARE
TN3382693Medicaid
TN3382693Medicaid