Provider Demographics
NPI:1851721369
Name:TRI-CITIES PEDIATRIC ENDOCRINOLOGY, PLLC
Entity Type:Organization
Organization Name:TRI-CITIES PEDIATRIC ENDOCRINOLOGY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY GWYN
Authorized Official - Middle Name:
Authorized Official - Last Name:ROPER
Authorized Official - Suffix:
Authorized Official - Credentials:MD, FAAP
Authorized Official - Phone:423-483-0828
Mailing Address - Street 1:PO BOX 3343
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37602-3343
Mailing Address - Country:US
Mailing Address - Phone:423-483-0828
Mailing Address - Fax:423-546-4103
Practice Address - Street 1:140 OLD GRAY STATION RD
Practice Address - Street 2:SUITE 200
Practice Address - City:GRAY
Practice Address - State:TN
Practice Address - Zip Code:37615-3612
Practice Address - Country:US
Practice Address - Phone:423-483-0828
Practice Address - Fax:423-546-4103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-19
Last Update Date:2015-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN37128261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty