Healthcare Provider Details

I. General information

NPI: 1366647455
Provider Name (Legal Business Name): EAST TENNESSEE CHILDREN'S HOSPITAL PRIMARY CARE CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2007
Last Update Date: 07/08/2025
Certification Date: 07/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 OAK RIDGE TURNPIKE
OAK RIDGE TN
37830-6916
US

IV. Provider business mailing address

PO BOX 15004
KNOXVILLE TN
37901-5004
US

V. Phone/Fax

Practice location:
  • Phone: 865-482-4088
  • Fax: 866-674-2033
Mailing address:
  • Phone: 865-541-8895
  • Fax: 865-633-4808

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080S0010X
TaxonomyPediatric Sports Medicine 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
# 4
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: CARYN HAWTHORNE
Title or Position: VICE PRESIDENT FINANCE
Credential:
Phone: 865-541-8181