Basic Information
| Provider Information | |||||||||
| NPI: | 1669472460 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RURAL HEALTH SERVICES CONSORTIUM OF UPPER EAST TENNESSEE INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | SNEEDVILLE 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: | 1861 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | SNEEDVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 378693645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237332131 | ||||||||
| FaxNumber: | 4237331055 | ||||||||
| 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 | 008 | 01 | CHAMPUS PROVIDER | OTHER | 4122525 | 01 | TN | BLUECROSS BLUESHIELD | OTHER | 021135900 | 01 | BLACKLUNG | OTHER | 3703864 | 01 | CIGNA/MEDICARE | OTHER | 4448160 | 05 | TN | MEDICAID |