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General NPI Number Information
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NPI Number | 1134473655
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Entity Type | Organization
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Legal Business Name | EAST TN FAMILY CARE LLC
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Dates
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Enumeration Date | 11/06/2012
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Last Update Date | 11/06/2012
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Provider Practice Location Address
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Address Line | 1548 PARKWAY SUITE 201
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City | SEVIERVILLE
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State | TN
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Zip | 37862-4019
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Country | US
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Telephone | 865-429-0208
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Fax | 865-429-0202
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Provider Business Mailing Address
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Address Line | PO BOX 1518
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City | PIGEON FORGE
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State | TN
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Zip | 37868-1518
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Country | US
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Telephone | 865-429-0208
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Fax | 865-429-0202
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Authorized Official
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Title or Position | OWNER/PHYSICIAN
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Name | DR. ROBERT MICKEY MAUGHON
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Credential | M.D.
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Telephone | 865-429-0208
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | MD16795
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License Number State | TN
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