Organization
MEDICALEDUCATIONASSISTANCECORPORATIONDBAUNIVERSITYPHYSICIANSPRACTICEGR
Active
Other names
ETSU ANDROLOGY LAB
Organization subpart
No
Provider details
NPI number
Authorized official
MR. RUSSELL E LEWIS (EXECUTIVE DIRECTOR)
(423) 433-6050
Entity
Organization
Contact information
Practice address
325 N STATE OF FRANKLIN RD, JOHNSON CITY, TN 37604
(423) 439-7272
(423) 439-7235
Mailing address
PO BOX 699, MOUNTAIN HOME, TN 37684-0699
(423) 433-6000
(423) 433-6060
Taxonomy
Speciality
Code
Description
License number
State
291U00000X
Clinical Medical Laboratory
Primary
3333
TN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
44D0718613
CLIA ID NUMBER
TN
Enumeration date
11/28/2006
Last updated
08/22/2018
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