MEDICARE: EAST TENNESSEE CARDIOVASCULAR SURGERY GROUP, P.C

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208G00000X	Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician		TN
2	171W00000X	Contractor		TN

General Provider Information

NPI Number	:	1679525448
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAST TENNESSEE CARDIOVASCULAR SURGERY GROUP, P.C

Provider Business Mailing Address
First Line	:	9125 CROSS PARK DRIVE
Second Line	:	SUITE 200
City	:	KNOXVILLE
State	:	TN
Zip	:	37923-4505
Country	:	US
Telephone Number	:	865-632-5900
Fax Number	:	865-637-2114

Provider Business Practice Location Address
First Line	:	9125 CROSS PARK DRIVE
Second Line	:	SUITE 200
City	:	KNOXVILLE
State	:	TN
Zip	:	37923-4505
Country	:	US
Telephone Number	:	865-632-5900
Fax Number	:	865-637-2114

Authorized Official
Title or Position	:	CAO
Name	:	MR. ROBERT CRAIG BRENT
Credential	:
Telephone Number	:	865-632-5900

Provider Enumeration Date	:	05/17/2006
Last Update Date	:	10/06/2015

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