MEDICARE: EAST TENNESSEE HEMATOLOGY-ONCOLOGY ASSOC

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	3336C0003X	Community/Retail Pharmacy	4926	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4444674	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER

General Provider Information

NPI Number	:	1508134768
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAST TENNESSEE HEMATOLOGY-ONCOLOGY ASSOC

Provider Business Mailing Address
First Line	:	310 N STATE OF FRANKLIN RD
Second Line	:
City	:	JOHNSON CITY
State	:	TN
Zip	:	37604-6008
Country	:	US
Telephone Number	:	423-926-3611
Fax Number	:	423-926-3073

Provider Business Practice Location Address
First Line	:	302 WESLEY ST STE 3
Second Line	:
City	:	JOHNSON CITY
State	:	TN
Zip	:	37601-1741
Country	:	US
Telephone Number	:	423-631-0523
Fax Number	:	423-631-0522

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MIKE COMBS
Credential	:
Telephone Number	:	423-461-7867

Provider Enumeration Date	:	12/02/2011
Last Update Date	:	12/02/2011

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