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NPI Code Detail

MEDICARE: EAST TENNESSEE CHILDREN'S HOSPITAL PRIMARY CARE CENTER INC.

MEDICARE: EAST TENNESSEE CHILDREN'S HOSPITAL PRIMARY CARE CENTER INC.
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
1363LP0200XPediatric Nurse Practitioner
2363LF0000XFamily Nurse Practitioner
3208000000XPediatrics Physician

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1669104196
Entity Type Code : Organization
Provider Name (Legal Business Name) : EAST TENNESSEE CHILDREN'S HOSPITAL PRIMARY CARE CENTER INC.
Provider Business Mailing Address
First Line : PO BOX 15004
Second Line :
City : KNOXVILLE
State : TN
Zip : 37901-5004
Country : US
Telephone Number : 865-541-8895
Fax Number : 865-633-4808
Provider Business Practice Location Address
First Line : 1705 ROANE STATE HWY
Second Line :
City : HARRIMAN
State : TN
Zip : 37748-8306
Country : US
Telephone Number : 865-316-5001
Fax Number : 865-376-3713
Authorized Official
Title or Position : CHIEF FINANCIAL OFFICER
Name : ANDREW ROSENDAHL
Credential :
Telephone Number : 865-541-8154
Provider Enumeration Date : 06/24/2022
Last Update Date : 01/14/2026

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