Healthcare Provider Details

I. General information

NPI: 1952367187
Provider Name (Legal Business Name): INTERNAL MEDICINE ASSOCIATES OF MCMINN COUNTY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2006
Last Update Date: 12/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 GRADY ROAD
ETOWAH TN
37331-0325
US

IV. Provider business mailing address

PO BOX 325
ETOWAH TN
37331-0325
US

V. Phone/Fax

Practice location:
  • Phone: 423-263-2444
  • Fax: 423-263-1553
Mailing address:
  • Phone: 423-263-2444
  • Fax: 423-263-1553

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number025977
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number029515
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number023767
License Number StateTN
# 4
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number025977
License Number StateTN
# 5
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number39591
License Number StateTN
# 6
Primary TaxonomyN
Taxonomy Code207RS0010X
TaxonomySports Medicine (Internal Medicine) Physician
License Number39591
License Number StateTN
# 7
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number023529
License Number StateTN

VIII. Authorized Official

Name: DR. RUSSELL BRANDON WATTERS III
Title or Position: CEO
Credential: MD
Phone: 423-263-2444