Provider Demographics
NPI:1861666562
Name:EAST TENNESSEE STATE UNIVERSITY
Entity Type:Organization
Organization Name:EAST TENNESSEE STATE UNIVERSITY
Other - Org Name:ETSU HIGH RISK CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO, VP FINANCE & ADMINISTRATION
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:D
Authorized Official - Last Name:COLLINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-439-5884
Mailing Address - Street 1:PO BOX 70403
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37614-1703
Mailing Address - Country:US
Mailing Address - Phone:423-439-4078
Mailing Address - Fax:423-439-4060
Practice Address - Street 1:325 N STATE OF FRANKLIN RD
Practice Address - Street 2:(GROUND FLOOR WITH PEDIATRICS)
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-6062
Practice Address - Country:US
Practice Address - Phone:423-439-4355
Practice Address - Fax:423-439-4607
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-15
Last Update Date:2008-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
3376497Medicare PIN
3376497Medicare Oscar/Certification