MEDICARE: EAST TENNESSEE ADDICTION SPECIALISTS

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	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center

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

General Provider Information

NPI Number	:	1770080632
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAST TENNESSEE ADDICTION SPECIALISTS

Provider Business Mailing Address
First Line	:	111 STATION DR BLDG 3
Second Line	:
City	:	MARYVILLE
State	:	TN
Zip	:	37804-4190
Country	:	US
Telephone Number	:	865-268-4360
Fax Number	:	865-329-6507

Provider Business Practice Location Address
First Line	:	111 STATION DR BLDG 3
Second Line	:
City	:	MARYVILLE
State	:	TN
Zip	:	37804-4190
Country	:	US
Telephone Number	:	865-268-4360
Fax Number	:

Authorized Official
Title or Position	:	COOWNER
Name	:	CLAY EUGENE STALCUP
Credential	:	MD
Telephone Number	:	865-406-2715

Provider Enumeration Date	:	04/09/2018
Last Update Date	:	01/08/2026

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