Provider Demographics
NPI:1912992272
Name:EARL EDWARD BREAZEALE, JR., MD, PC
Entity Type:Organization
Organization Name:EARL EDWARD BREAZEALE, JR., MD, PC
Other - Org Name:THE BREAZEALE CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BREAZEALE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:865-342-0300
Mailing Address - Street 1:2068 LAKESIDE CENTRE WAY
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37922
Mailing Address - Country:US
Mailing Address - Phone:865-342-0300
Mailing Address - Fax:865-342-0300
Practice Address - Street 1:2068 LAKESIDE CENTRE WAY
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37922-6591
Practice Address - Country:US
Practice Address - Phone:865-342-0300
Practice Address - Fax:865-342-0301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-13
Last Update Date:2010-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3377019Medicare ID - Type UnspecifiedGROUP NUMBER