Healthcare Provider Details

I. General information

NPI: 1669104196
Provider Name (Legal Business Name): EAST TENNESSEE CHILDREN'S PRIMARY CARE CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2022
Last Update Date: 09/05/2026
Certification Date: 09/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1705 ROANE STATE HWY
HARRIMAN TN
37748-8306
US

IV. Provider business mailing address

PO BOX 50068
KNOXVILLE TN
37950-0068
US

V. Phone/Fax

Practice location:
  • Phone: 865-316-5001
  • Fax: 865-376-3713
Mailing address:
  • Phone: 865-541-8895
  • Fax: 865-633-4808

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: ANDREW ROSENDAHL
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 865-541-8154