Provider Demographics
NPI:1255376083
Name:EAST TENNESSEE FOOT CLINIC PC
Entity type:Organization
Organization Name:EAST TENNESSEE FOOT CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LAUREL
Authorized Official - Middle Name:BURGER
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:865-981-4595
Mailing Address - Street 1:603 SMITHVIEW DR
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37803-6100
Mailing Address - Country:US
Mailing Address - Phone:865-981-4595
Mailing Address - Fax:865-981-4544
Practice Address - Street 1:603 SMITHVIEW DR
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37803-6100
Practice Address - Country:US
Practice Address - Phone:865-981-4595
Practice Address - Fax:865-981-4544
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-17
Last Update Date:2010-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN641213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNU71317Medicare UPIN
TN3733969Medicare PIN
TN5763670001Medicare NSC