Provider Demographics
NPI:1952367187
Name:INTERNAL MEDICINE ASSOCIATES OF MCMINN COUNTY PC
Entity Type:Organization
Organization Name:INTERNAL MEDICINE ASSOCIATES OF MCMINN COUNTY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:BRANDON
Authorized Official - Last Name:WATTERS
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:423-263-2444
Mailing Address - Street 1:PO BOX 325
Mailing Address - Street 2:
Mailing Address - City:ETOWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37331-0325
Mailing Address - Country:US
Mailing Address - Phone:423-263-2444
Mailing Address - Fax:423-263-1553
Practice Address - Street 1:301 GRADY ROAD
Practice Address - Street 2:
Practice Address - City:ETOWAH
Practice Address - State:TN
Practice Address - Zip Code:37331-0325
Practice Address - Country:US
Practice Address - Phone:423-263-2444
Practice Address - Fax:423-263-1553
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-25
Last Update Date:2009-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN025977207R00000X, 207RN0300X
TN029515207R00000X
TN023529207R00000X
TN023767207R00000X
TN39591207R00000X, 207RS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
No207RS0010XAllopathic & Osteopathic PhysiciansInternal MedicineSports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNCE0552OtherMEDICARE RR
TNCE0552OtherMEDICARE RR