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General NPI Number Information
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NPI Number | 1851721369
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Entity Type | Organization
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Legal Business Name | TRI-CITIES PEDIATRIC ENDOCRINOLOGY, PLLC
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Dates
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Enumeration Date | 11/19/2013
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Last Update Date | 02/05/2015
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Provider Practice Location Address
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Address Line | 140 OLD GRAY STATION RD SUITE 200
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City | GRAY
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State | TN
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Zip | 37615-3612
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Country | US
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Telephone | 423-483-0828
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Fax | 423-546-4103
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Provider Business Mailing Address
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Address Line | PO BOX 3343
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City | JOHNSON CITY
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State | TN
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Zip | 37602-3343
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Country | US
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Telephone | 423-483-0828
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Fax | 423-546-4103
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Authorized Official
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Title or Position | OWNER
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Name | DR. MARY GWYN ROPER
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Credential | M.D., F.A.A.P.
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Telephone | 423-483-0828
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number | 37128
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License Number State | TN
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