Basic Information
Provider Information | |||||||||
NPI: | 1396745162 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | RURAL HEALTH SERVICES CONSORTIUM OF UPPER EAST TENNESSEE INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | DRY CREEK MEDICAL CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 850 | ||||||||
Address2: |   | ||||||||
City: | ROGERSVILLE | ||||||||
State: | TN | ||||||||
PostalCode: | 378570850 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4232729163 | ||||||||
FaxNumber: | 4239216920 | ||||||||
Practice Location | |||||||||
Address1: | 1826 N MAIN AVE | ||||||||
Address2: |   | ||||||||
City: | ERWIN | ||||||||
State: | TN | ||||||||
PostalCode: | 376508932 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4237436135 | ||||||||
FaxNumber: | 4237430035 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/22/2005 | ||||||||
LastUpdateDate: | 10/10/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BUCK | ||||||||
AuthorizedOfficialFirstName: | LINDA | ||||||||
AuthorizedOfficialMiddleName: | W | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 4232729163 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
ID | Type | State | Issuer | Description | 3703868 | 01 |   | CIGNA MEDICARE | OTHER | 020021000 | 01 |   | BLACKLUNG | OTHER | 002 | 01 |   | CHAMPUS PROVIDER | OTHER | 4122525 | 01 | TN | BLUECROSS BLUESHIELD | OTHER | 4448096 | 05 | TN |   | MEDICAID |