Healthcare Provider Details

I. General information

NPI: 1609388438
Provider Name (Legal Business Name): EAST TENNESSEE CHILDREN'S HOSPITAL ASSOCIATION, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2017
Last Update Date: 04/07/2022
Certification Date: 04/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1060 PEERLESS XING NW STE 100
CLEVELAND TN
37312-3785
US

IV. Provider business mailing address

PO BOX 15004
KNOXVILLE TN
37901-5004
US

V. Phone/Fax

Practice location:
  • Phone: 865-522-0420
  • Fax: 877-801-6771
Mailing address:
  • Phone: 865-541-8895
  • Fax: 865-633-4808

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number
License Number State

VIII. Authorized Official

Name: MARK B MASON
Title or Position: REGIONAL PRACTICE ADMINISTRATOR
Credential:
Phone: 865-541-8053