Provider Demographics
NPI:1841362555
Name:TRI-CITY PEDIACTRIC CARDIOLOGY P C
Entity type:Organization
Organization Name:TRI-CITY PEDIACTRIC CARDIOLOGY P C
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ASHOK
Authorized Official - Middle Name:V
Authorized Official - Last Name:MEHTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:423-610-1099
Mailing Address - Street 1:PO BOX 3953
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37602-3953
Mailing Address - Country:US
Mailing Address - Phone:423-610-1099
Mailing Address - Fax:423-610-1166
Practice Address - Street 1:2312 KNOB CREEK RD
Practice Address - Street 2:SUITE 208
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-2367
Practice Address - Country:US
Practice Address - Phone:423-610-1099
Practice Address - Fax:423-610-1166
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2012-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric CardiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3722336Medicaid
TN3722336Medicaid