MEDICARE: KINGSPORT ANESTHESIA, PLC

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	174400000X	Specialist	MD0000034445	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	4067843	OTHER	TN	BCBS TN PROVIDER NUMBER

General Provider Information

NPI Number	:	1609988930
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KINGSPORT ANESTHESIA, PLC

Provider Business Mailing Address
First Line	:	3101 BROWNS MILL RD STE 6 PMB 386
Second Line	:
City	:	JOHNSON CITY
State	:	TN
Zip	:	37604-4100
Country	:	US
Telephone Number	:	423-854-0001
Fax Number	:	423-854-0002

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	:	423-283-7302
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. LORNA K EHRENFRIED
Credential	:	M.D.
Telephone Number	:	423-854-0001

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	08/22/2020

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