MEDICARE: EAST TENNESSEE MEDICAL ASSOCIATES, P.C.

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	207RN0300X	Nephrology Physician	MD6775	TN

General Provider Information

NPI Number	:	1619089034
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAST TENNESSEE MEDICAL ASSOCIATES, P.C.

Provider Business Mailing Address
First Line	:	107 WOODLAWN DR
Second Line	:
City	:	JOHNSON CITY
State	:	TN
Zip	:	37604-5978
Country	:	US
Telephone Number	:	423-929-7158
Fax Number	:	423-928-9625

Provider Business Practice Location Address
First Line	:	107 WOODLAWN DR
Second Line	:
City	:	JOHNSON CITY
State	:	TN
Zip	:	37604-5978
Country	:	US
Telephone Number	:	423-929-7158
Fax Number	:	423-928-9625

Authorized Official
Title or Position	:	VICE-PRESIDENT
Name	:	DR. STANLEY E VERMILLION
Credential	:	M.D.
Telephone Number	:	423-929-7158

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	01/13/2010

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