Provider Demographics
NPI:1053895268
Name:EAST TENNESSEE MEDICAL GROUP, P.C.
Entity type:Organization
Organization Name:EAST TENNESSEE MEDICAL GROUP, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KHAIRIYA
Authorized Official - Middle Name:C
Authorized Official - Last Name:BRYANT
Authorized Official - Suffix:
Authorized Official - Credentials:ESQ
Authorized Official - Phone:864-343-0010
Mailing Address - Street 1:25 AIRPARK CT
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607-6188
Mailing Address - Country:US
Mailing Address - Phone:864-343-0010
Mailing Address - Fax:864-312-6927
Practice Address - Street 1:281 UNDERPASS DR
Practice Address - Street 2:
Practice Address - City:ONEIDA
Practice Address - State:TN
Practice Address - Zip Code:37841-5885
Practice Address - Country:US
Practice Address - Phone:423-569-5454
Practice Address - Fax:423-569-5858
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-24
Last Update Date:2018-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty