Provider Demographics
NPI:1982987830
Name:PEDIATRIC EAR, NOSE & THROAT ASSOCIATES, P.C.
Entity type:Organization
Organization Name:PEDIATRIC EAR, NOSE & THROAT ASSOCIATES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOE
Authorized Official - Middle Name:A
Authorized Official - Last Name:GRAVES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:865-673-8229
Mailing Address - Street 1:2100 W CLINCH AVE
Mailing Address - Street 2:SUITE 330
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37916-2219
Mailing Address - Country:US
Mailing Address - Phone:865-673-8229
Mailing Address - Fax:865-673-8893
Practice Address - Street 1:2100 W CLINCH AVE
Practice Address - Street 2:SUITE 330
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37916-2219
Practice Address - Country:US
Practice Address - Phone:865-673-8229
Practice Address - Fax:865-673-8893
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-27
Last Update Date:2011-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN23686174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3068753Medicaid