Provider Demographics
NPI:1538175336
Name:SOUTHEAST TENNESSEE ORTHOPAEDICS, INC
Entity type:Organization
Organization Name:SOUTHEAST TENNESSEE ORTHOPAEDICS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:V
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:423-472-1567
Mailing Address - Street 1:102 DUNHILL PLACE NW
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37311-3883
Mailing Address - Country:US
Mailing Address - Phone:423-472-1567
Mailing Address - Fax:
Practice Address - Street 1:102 DUNHILL PL NW
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37311-3883
Practice Address - Country:US
Practice Address - Phone:423-472-1567
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-01
Last Update Date:2010-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD15518207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1083658496OtherNPI STONE
1427094747OtherNPI JOHNSON
TN3009032Medicare ID - Type UnspecifiedMEDICARE NUMBER
1427094747OtherNPI JOHNSON
TN3664201Medicare ID - Type UnspecifiedMEDICARE IND # SMITH
Q62756Medicare UPIN
TN3007227Medicare ID - Type UnspecifiedMEDICARE IND (JOHNSON)
S96199Medicare UPIN
TN3386855Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER
B04766Medicare UPIN
3668897Medicare ID - Type UnspecifiedMEDICARE IND # BRYAN
TN3197794Medicare ID - Type UnspecifiedMEDICARE IND # BEASLEY
1083658496OtherNPI STONE