Healthcare Provider Details

I. General information

NPI: 1336629021
Provider Name (Legal Business Name): MEDICAL EDUCATION ASSISTANCE CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2018
Last Update Date: 08/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 W MARKET ST
JOHNSON CITY TN
37604
US

IV. Provider business mailing address

PO BOX 699
MOUNTAIN HOME TN
37684-0699
US

V. Phone/Fax

Practice location:
  • Phone: 423-928-0380
  • Fax: 423-928-0557
Mailing address:
  • Phone: 423-433-6039
  • Fax: 423-433-6060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QS1000X
TaxonomyStudent Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: RUSSELL E. LEWIS
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 423-433-6050