Basic Information
| Provider Information | |||||||||
| NPI: | 1366452914 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EAST TENNESSEE BRAIN & SPINE CENTER, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9150 | ||||||||
| Address2: | |||||||||
| City: | PADUCAH | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420029150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707449600 | ||||||||
| FaxNumber: | 2707440834 | ||||||||
| Practice Location | |||||||||
| Address1: | 701 MED TECH PKWY | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376042365 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232328301 | ||||||||
| FaxNumber: | 4232328304 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2006 | ||||||||
| LastUpdateDate: | 06/06/2012 | ||||||||
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| AuthorizedOfficialLastName: | WILES | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4232328301 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | TN | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363LA2200X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LF0000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 207T00000X | TN | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neurological Surgery |
ID Information
| ID | Type | State | Issuer | Description | 4069221 | 01 | TN | BLUE CROSS/BLUE SHIELD | OTHER | 3721061 | 05 | TN | MEDICAID | 1366452914 | 05 | VA | MEDICAID | 5903904 | 05 | NC | MEDICAID | 7100132610 | 05 | KY | MEDICAID |