Healthcare Provider Details

I. General information

NPI: 1235640467
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: 10/16/2017
Last Update Date: 09/05/2026
Certification Date: 09/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10857 HARDIN VALLEY RD
KNOXVILLE TN
37932-1410
US

IV. Provider business mailing address

PO BOX 50068
KNOXVILLE TN
37950-0068
US

V. Phone/Fax

Practice location:
  • Phone: 865-690-2682
  • Fax: 866-529-5509
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 Code261QP2300X
TaxonomyPrimary Care Clinic/Center
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