Basic Information
| Provider Information | |||||||||
| NPI: | 1184089559 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ETSU PHYSICIANS & ASSOCIATES | ||||||||
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| OtherOrganizationName: | OFFICE OF OB/GYN ELIZABETHTON | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1505 W ELK AVE STE 1 | ||||||||
| Address2: | |||||||||
| City: | ELIZABETHTON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376432848 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4235437919 | ||||||||
| FaxNumber: | 4235435323 | ||||||||
| Practice Location | |||||||||
| Address1: | 1505 W ELK AVE STE 1 | ||||||||
| Address2: | |||||||||
| City: | ELIZABETHTON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37643 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4235437919 | ||||||||
| FaxNumber: | 4235435323 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2015 | ||||||||
| LastUpdateDate: | 08/22/2018 | ||||||||
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| AuthorizedOfficialLastName: | LEWIS | ||||||||
| AuthorizedOfficialFirstName: | RUSSELL | ||||||||
| AuthorizedOfficialMiddleName: | EUGENE | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4237941300 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
No ID Information.