Provider Demographics
NPI:1184089559
Name:ETSU PHYSICIANS & ASSOCIATES
Entity type:Organization
Organization Name:ETSU PHYSICIANS & ASSOCIATES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-794-1300
Mailing Address - Street 1:1505 W ELK AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTON
Mailing Address - State:TN
Mailing Address - Zip Code:37643-2848
Mailing Address - Country:US
Mailing Address - Phone:423-543-7919
Mailing Address - Fax:423-543-5323
Practice Address - Street 1:1505 W ELK AVE STE 1
Practice Address - Street 2:
Practice Address - City:ELIZABETHTON
Practice Address - State:TN
Practice Address - Zip Code:37643
Practice Address - Country:US
Practice Address - Phone:423-543-7919
Practice Address - Fax:423-543-5323
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-29
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty