=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538175336
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHEAST TENNESSEE ORTHOPAEDICS, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/01/2006
-----------------------------------------------------
Last Update Date | 12/27/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 102 DUNHILL PL NW
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37311-3883
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-472-1567
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 102 DUNHILL PLACE NW
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37311-3883
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-472-1567
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PARTNER
-----------------------------------------------------
Name | DANIEL V. JOHNSON
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 423-472-1567
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | MD15518
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------