Basic Information
| Provider Information | |||||||||
| NPI: | 1316216336 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEDICAL EDUCATION ASSISTANCE CORPORATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ST. JUDE'S TRI-CITIES AFFILIATE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2204 | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376052204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234336050 | ||||||||
| FaxNumber: | 4234336060 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 N STATE OF FRANKLIN RD | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234313950 | ||||||||
| FaxNumber: | 4234313958 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2011 | ||||||||
| LastUpdateDate: | 08/22/2018 | ||||||||
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| AuthorizedOfficialLastName: | LEWIS | ||||||||
| AuthorizedOfficialFirstName: | RUSSELL | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4234336050 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0207X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Hematology-Oncology |
No ID Information.