Basic Information
| Provider Information | |||||||||
| NPI: | 1467552216 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EAST TENNESSEE EAR, NOSE & THROAT SPECIALISTS, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 800 OAK RIDGE TURNPIKE | ||||||||
| Address2: | SUITE C-100 | ||||||||
| City: | OAK RIDGE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37830 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8654832288 | ||||||||
| FaxNumber: | 8654824400 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 OAK RIDGE TURNPIKE | ||||||||
| Address2: | SUITE C-100 | ||||||||
| City: | OAK RIDGE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37830 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8654832288 | ||||||||
| FaxNumber: | 8654824400 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2006 | ||||||||
| LastUpdateDate: | 12/03/2007 | ||||||||
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| AuthorizedOfficialLastName: | BAKER | ||||||||
| AuthorizedOfficialFirstName: | CHRIS | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8654834759 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 65904229 | 05 | KY | MEDICAID | 3373518 | 05 | TN | MEDICAID |