Basic Information
| Provider Information | |||||||||
| NPI: | 1306251269 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EMBERESH | ||||||||
| FirstName: | MYESA | ||||||||
| MiddleName: | H | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 699 | ||||||||
| Address2: | |||||||||
| City: | MOUNTAIN HOME | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376840699 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234313950 | ||||||||
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| Practice Location | |||||||||
| Address1: | 400 N. STATE OF FRANKLIN ROAD | ||||||||
| Address2: | ST. JUDE'S TRI-CITIES AFFILIATE | ||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234313950 | ||||||||
| FaxNumber: | 4234313958 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2014 | ||||||||
| LastUpdateDate: | 07/31/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/31/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2080P0207X | MD61093 | TN | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Hematology-Oncology |
ID Information
| ID | Type | State | Issuer | Description | 1306251269 | 05 | NY | MEDICAID |