Provider Demographics
NPI:1215056171
Name:SPECIALTY MEDICAL SERVICES, INC
Entity type:Organization
Organization Name:SPECIALTY MEDICAL SERVICES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:D
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:423-570-0097
Mailing Address - Street 1:188 16TH AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:TN
Mailing Address - Zip Code:37321-1038
Mailing Address - Country:US
Mailing Address - Phone:423-570-0097
Mailing Address - Fax:423-570-0808
Practice Address - Street 1:188 16TH AVE STE 104
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:TN
Practice Address - Zip Code:37321-1038
Practice Address - Country:US
Practice Address - Phone:423-570-0097
Practice Address - Fax:423-570-0808
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD13288207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4053237OtherBC BS
TN3376010Medicaid
TN3376010Medicare ID - Type UnspecifiedGRP