Provider Demographics
NPI:1013675578
Name:EAST BRAINERD PODIATRY CENTER PLLC
Entity Type:Organization
Organization Name:EAST BRAINERD PODIATRY CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:REVA
Authorized Official - Middle Name:FAYE
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-285-4970
Mailing Address - Street 1:7694 E BRAINERD RD
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-3162
Mailing Address - Country:US
Mailing Address - Phone:423-316-0957
Mailing Address - Fax:
Practice Address - Street 1:7694 E BRAINERD RD
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-3162
Practice Address - Country:US
Practice Address - Phone:423-316-0957
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-02
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty