Healthcare Provider Details

I. General information

NPI: 1063437994
Provider Name (Legal Business Name): TRI-CITIES ENDOSCOPY CENTER PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 10/21/2022
Certification Date: 10/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10461 WALLACE ALLEY ST
KINGSPORT TN
37663-3936
US

IV. Provider business mailing address

10461 WALLACE ALLEY ST
KINGSPORT TN
37663-3936
US

V. Phone/Fax

Practice location:
  • Phone: 423-279-1400
  • Fax:
Mailing address:
  • Phone: 423-279-1400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QE0800X
TaxonomyEndoscopy Clinic/Center
License Number151
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MICHELLE CARMELA MERRITT
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 423-279-1414