Provider Demographics
NPI:1669584991
Name:EAST TENNESSEE ANESTHESIA PROVIDERS, PC
Entity type:Organization
Organization Name:EAST TENNESSEE ANESTHESIA PROVIDERS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VIKTOR
Authorized Official - Middle Name:P
Authorized Official - Last Name:SULKOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:423-854-0001
Mailing Address - Street 1:3101 BROWNS MILL RD STE 6 PMB 386
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-4100
Mailing Address - Country:US
Mailing Address - Phone:423-854-0001
Mailing Address - Fax:423-854-0002
Practice Address - Street 1:10461 WALLACE ALLEY ST
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37663-3936
Practice Address - Country:US
Practice Address - Phone:423-279-1400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2011-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000010318174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3379190Medicaid
TN4051152OtherBCBS TN PROVIDER NUMBER
TN4051167OtherBCBS TN GRP PROVIDER NUMB
TNB03565Medicare UPIN
TN4051167OtherBCBS TN GRP PROVIDER NUMB
TN3379190Medicaid