Basic Information
| Provider Information | |||||||||
| NPI: | 1184801631 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EAST TENNESSEE PRIMARY CARE, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 80982 | ||||||||
| Address2: | |||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234954349 | ||||||||
| FaxNumber: | 4234954934 | ||||||||
| Practice Location | |||||||||
| Address1: | 3300 WILCOX BLVD. | ||||||||
| Address2: | |||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4238039180 | ||||||||
| FaxNumber: | 4238039181 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/28/2008 | ||||||||
| LastUpdateDate: | 01/11/2017 | ||||||||
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| AuthorizedOfficialLastName: | DUNBAR-DAVIES | ||||||||
| AuthorizedOfficialFirstName: | WINNIFRED | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DOCTOR/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4237785584 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 27162 | TN | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 44104835 | 01 | TN | TENNCARE SELECT | OTHER | 4104835 | 01 | TN | BLUE CROSS OF TENNESSEE | OTHER | 5487562 | 01 | TN | CIGNA | OTHER | TN0101 | 01 | TN | UHC OF THE RIVER VALLEY | OTHER |