Provider Demographics
NPI:1063437994
Name:TRI-CITIES ENDOSCOPY CENTER PC
Entity type:Organization
Organization Name:TRI-CITIES ENDOSCOPY CENTER PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:CARMELA
Authorized Official - Last Name:MERRITT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-279-1414
Mailing Address - Street 1:10461 WALLACE ALLEY ST
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37663-3936
Mailing Address - Country:US
Mailing Address - Phone:423-279-1400
Mailing Address - Fax:
Practice Address - Street 1:10461 WALLACE ALLEY ST
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37663-3936
Practice Address - Country:US
Practice Address - Phone:423-279-1400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2022-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN151261QE0800X
261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
No261QE0800XAmbulatory Health Care FacilitiesClinic/CenterEndoscopy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN44C0001122Medicare ID - Type UnspecifiedMEDICARE ID
TN3574530Medicare UPIN