Basic Information
| Provider Information | |||||||||
| NPI: | 1891861373 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEDICALEDUCATIONASSISTANCECORPORATIONDBAUNIVERSITYPHYSICIANSPRACTICEGR | ||||||||
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| OtherOrganizationName: | ETSU ANDROLOGY LAB | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 699 | ||||||||
| Address2: | |||||||||
| City: | MOUNTAIN HOME | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376840699 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234336000 | ||||||||
| FaxNumber: | 4234336060 | ||||||||
| Practice Location | |||||||||
| Address1: | 325 N STATE OF FRANKLIN RD | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234397272 | ||||||||
| FaxNumber: | 4234397235 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2006 | ||||||||
| 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 | 291U00000X | 3333 | TN | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 44D0718613 | 01 | TN | CLIA ID NUMBER | OTHER |