MEDICARE: EAST TENNESSEE CHILDREN'S HOSPITAL PRIMARY CARE CENTER, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	363LP0200X	Pediatric Nurse Practitioner
2	261QP2300X	Primary Care Clinic/Center
3	208000000X	Pediatrics Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1457557134
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAST TENNESSEE CHILDREN'S HOSPITAL PRIMARY CARE CENTER, INC.

Provider Business Mailing Address
First Line	:	PO BOX 15004
Second Line	:
City	:	KNOXVILLE
State	:	TN
Zip	:	37901-5004
Country	:	US
Telephone Number	:	865-541-8895
Fax Number	:	865-633-4808

Provider Business Practice Location Address
First Line	:	2130 N CHARLES G SEIVERS BLVD STE 4
Second Line	:
City	:	CLINTON
State	:	TN
Zip	:	37716-6705
Country	:	US
Telephone Number	:	865-457-4044
Fax Number	:	866-699-4833

Authorized Official
Title or Position	:	CHIEF FINANCIAL OFFICER
Name	:	ANDREW ROSENDAHL
Credential	:
Telephone Number	:	865-541-8154

Provider Enumeration Date	:	06/21/2007
Last Update Date	:	01/14/2026

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