Provider Demographics
NPI:1356379093
Name:EMMAUS COMMUNITY HEALTHCARE, PLLC
Entity type:Organization
Organization Name:EMMAUS COMMUNITY HEALTHCARE, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:L
Authorized Official - Last Name:BACKUS
Authorized Official - Suffix:III
Authorized Official - Credentials:DO
Authorized Official - Phone:423-538-5202
Mailing Address - Street 1:509 MEDTECH PKWY
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604
Mailing Address - Country:US
Mailing Address - Phone:423-952-2122
Mailing Address - Fax:423-952-2145
Practice Address - Street 1:6419 BRISTOL HIGHWAY
Practice Address - Street 2:
Practice Address - City:PINEY FLATS
Practice Address - State:TN
Practice Address - Zip Code:37686
Practice Address - Country:US
Practice Address - Phone:423-538-5202
Practice Address - Fax:423-538-8208
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-29
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3726460Medicaid
TNDD0861OtherRR
TN3726460Medicare PIN
TNDD0861OtherRR