Provider Demographics
NPI:1306251269
Name:EMBERESH, MYESA H
Entity type:Individual
Prefix:
First Name:MYESA
Middle Name:H
Last Name:EMBERESH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 699
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:TN
Mailing Address - Zip Code:37684-0699
Mailing Address - Country:US
Mailing Address - Phone:423-431-3950
Mailing Address - Fax:
Practice Address - Street 1:400 N. STATE OF FRANKLIN ROAD
Practice Address - Street 2:ST. JUDE'S TRI-CITIES AFFILIATE
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604
Practice Address - Country:US
Practice Address - Phone:423-431-3950
Practice Address - Fax:423-431-3958
Is Sole Proprietor?:No
Enumeration Date:2014-06-29
Last Update Date:2020-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TNMD610932080P0207X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1306251269Medicaid