Provider Demographics
NPI:1295941300
Name:SCENIC CITY ORTHOPAEDICS & SPORTS MEDICINE, PLLC
Entity type:Organization
Organization Name:SCENIC CITY ORTHOPAEDICS & SPORTS MEDICINE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:P
Authorized Official - Last Name:CLARKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:423-624-8588
Mailing Address - Street 1:2707 CITICO AVE
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37406-3402
Mailing Address - Country:US
Mailing Address - Phone:423-624-8588
Mailing Address - Fax:423-622-3069
Practice Address - Street 1:2707 CITICO AVE
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37406-3402
Practice Address - Country:US
Practice Address - Phone:423-624-8588
Practice Address - Fax:423-622-3069
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2010-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN21142207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3732227Medicare ID - Type Unspecified