Provider Demographics
NPI:1285723585
Name:HOLSTON PEDIATRIC AND ADOLESCENT CARE
Entity type:Organization
Organization Name:HOLSTON PEDIATRIC AND ADOLESCENT CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:R
Authorized Official - Last Name:MORIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:423-378-6202
Mailing Address - Street 1:698 CLINCHFIELD ST
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-3630
Mailing Address - Country:US
Mailing Address - Phone:423-378-6202
Mailing Address - Fax:423-246-8907
Practice Address - Street 1:698 CLINCHFIELD ST
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-3630
Practice Address - Country:US
Practice Address - Phone:423-378-6202
Practice Address - Fax:423-246-8907
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD00000119462080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNB03869Medicare UPIN