Healthcare Provider Details

I. General information

NPI: 1538175336
Provider Name (Legal Business Name): SOUTHEAST TENNESSEE ORTHOPAEDICS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 12/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 DUNHILL PL NW
CLEVELAND TN
37311-3883
US

IV. Provider business mailing address

102 DUNHILL PLACE NW
CLEVELAND TN
37311-3883
US

V. Phone/Fax

Practice location:
  • Phone: 423-472-1567
  • Fax:
Mailing address:
  • Phone: 423-472-1567
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberMD15518
License Number StateTN

VIII. Authorized Official

Name: DANIEL V. JOHNSON
Title or Position: PARTNER
Credential: M.D.
Phone: 423-472-1567