Provider Demographics
NPI:1750301685
Name:SURGICAL GROUP OF JOHNSON CITY, MPC
Entity Type:Organization
Organization Name:SURGICAL GROUP OF JOHNSON CITY, MPC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:D
Authorized Official - Last Name:WATSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:423-975-0764
Mailing Address - Street 1:310 N STATE OF FRANKLIN RD STE 404
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-6063
Mailing Address - Country:US
Mailing Address - Phone:423-975-0764
Mailing Address - Fax:423-975-0141
Practice Address - Street 1:310 N STATE OF FRANKLIN RD STE 404
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-6063
Practice Address - Country:US
Practice Address - Phone:423-975-0764
Practice Address - Fax:423-975-0141
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD19488208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3722620Medicare ID - Type UnspecifiedMEDICARE GROUP PROVIDER N