Basic Information
Provider Information | |||||||||
NPI: | 1164062659 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MEDICAL EDUCATION ASSISTANCE CORPORATION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 699 | ||||||||
Address2: |   | ||||||||
City: | MOUNTAIN HOME | ||||||||
State: | TN | ||||||||
PostalCode: | 376840699 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4234336039 | ||||||||
FaxNumber: | 4234336060 | ||||||||
Practice Location | |||||||||
Address1: | 2423 SUSANNAH ST | ||||||||
Address2: |   | ||||||||
City: | JOHNSON CITY | ||||||||
State: | TN | ||||||||
PostalCode: | 376011749 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4239159257 | ||||||||
FaxNumber: | 4234394607 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/13/2020 | ||||||||
LastUpdateDate: | 01/13/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LEWIS | ||||||||
AuthorizedOfficialFirstName: | RUSSELL | ||||||||
AuthorizedOfficialMiddleName: | E. | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 4234336050 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/13/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   |
No ID Information.