Provider Demographics
NPI:1154780716
Name:EAST TENNESSEE STATE UNIVERSITY
Entity type:Organization
Organization Name:EAST TENNESSEE STATE UNIVERSITY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO, VP FINANCE ADMIN
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:D
Authorized Official - Last Name:COLLINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-439-5884
Mailing Address - Street 1:PO BOX 70403
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37614-1703
Mailing Address - Country:US
Mailing Address - Phone:423-439-4071
Mailing Address - Fax:423-439-4060
Practice Address - Street 1:2151 CENTURY LN
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-4469
Practice Address - Country:US
Practice Address - Phone:423-926-2500
Practice Address - Fax:423-926-5999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-11
Last Update Date:2016-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN53993336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy