Healthcare Provider Details

I. General information

NPI: 1326370784
Provider Name (Legal Business Name): EAST TENNESSEE GASTROENTEROLOGY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2010
Last Update Date: 04/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2404 CHAMBLISS AVE NW
CLEVELAND TN
37311-3848
US

IV. Provider business mailing address

2404 CHAMBLISS AVE NW
CLEVELAND TN
37311-3848
US

V. Phone/Fax

Practice location:
  • Phone: 423-339-2000
  • Fax:
Mailing address:
  • Phone: 423-339-2000
  • Fax: 423-339-2043

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number2102
License Number StateTN

VIII. Authorized Official

Name: DR. GEORGE SAMUEL
Title or Position: PRESIDENT
Credential: D.O.
Phone: 423-339-2000