Basic Information
| Provider Information | |||||||||
| NPI: | 1144290552 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COMBS | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | P | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 509 MED TECH PKWY STE 100 | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376042579 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4233026565 | ||||||||
| FaxNumber: | 4239522175 | ||||||||
| Practice Location | |||||||||
| Address1: | 115 JUDGE GRESHAM RD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | GRAY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376156213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234772885 | ||||||||
| FaxNumber: | 4234770113 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2006 | ||||||||
| LastUpdateDate: | 05/24/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 26795 | TN | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 0101259182 | VA | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080A0000X | 0101259182 | VA | N | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine | 2080A0000X | 26795 | TN | Y | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3095016 | 05 | VA | MEDICAID |