MEDICARE: EAST TENNESSEE GASTROENTEROLOGY, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RG0100X	Gastroenterology Physician	2102	TN

General Provider Information

NPI Number	:	1326370784
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAST TENNESSEE GASTROENTEROLOGY, PLLC

Provider Business Mailing Address
First Line	:	2404 CHAMBLISS AVE NW
Second Line	:
City	:	CLEVELAND
State	:	TN
Zip	:	37311-3848
Country	:	US
Telephone Number	:	423-339-2000
Fax Number	:	423-339-2043

Provider Business Practice Location Address
First Line	:	2404 CHAMBLISS AVE NW
Second Line	:
City	:	CLEVELAND
State	:	TN
Zip	:	37311-3848
Country	:	US
Telephone Number	:	423-339-2000
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. GEORGE SAMUEL
Credential	:	D.O.
Telephone Number	:	423-339-2000

Provider Enumeration Date	:	02/09/2010
Last Update Date	:	04/01/2013

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