NPIMap

Organization Active NPI

East Tennessee State University

Doing business as Johnson City Downtown Clinic Day Center

  • Federally Qualified Health Center (FQHC)
  • Johnson City, TN
National Provider Identifier
1093990608
Registry record updated Jul 21, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
EAST TENNESSEE STATE UNIVERSITY
Doing business as
Johnson City Downtown Clinic Day Center
Practice address
202 W Fairview Ave
Johnson City, TN 37604-5611
Phone
(423) 434-0894
Fax
(423) 434-0666
NPI assigned
Jan 2, 2008
Last updated
Jul 21, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 21, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Betty J. King
Title
Acting Chief Financial Officer
Phone
(423) 439-4414

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X Primary

Addresses

Primary practice location

202 W Fairview Ave
Johnson City, TN 37604-5611

Mailing address

365 Stout Drive Box 70403
Johnson City, TN 37614-1703
Phone (423) 439-4515

Other names 1

  • Johnson City Downtown Clinic Day Center Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in TN2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20031212000403 TN Part B Supplier - Clinic/Group Practice 2769394774 Receives reassigned benefits from 44 practitioners
12 other NPIs on this enrollment
Practice locations: Johnson City, TN; Sneedville, TN
O20140416000866 TN Part A Provider - Federally Qualified Health Center (FQHC) 2769394774 Practice locations: Johnson City, TN

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1093990608. Details of each certification follow.

Federally qualified health center certification: CCN 441900

Legal name
EAST TENNESSEE STATE UNIVERSITY
Doing business as
JOHNSON CITY DOWNTOWN CLINIC DAY CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Aug 11, 2005
Last certification
Aug 11, 2005
Ownership / control type
Non-profit – corporation
Organization structure
OtherNon-profit
Incorporated
Aug 11, 2005 in TN
Enrollment address
202 W Fairview Ave
Johnson City, TN 37604-5611

Other NPIs with the same Medicare PAC ID 3

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 12

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory
Tax ID family
Etsu Behavioral Health and Wellness Clinic20 organizations share this tax ID, including this one

Other organizations with this tax ID 19

Organizations that report the same tax identification number in the National Provider Directory.

View all 19

Locations

202 W Fairview Ave
Johnson City, TN 37604
Phone (423) 439-7371

837 Pardee St
Johnson City, TN 37601
Phone (423) 926-6396

Ownership & related parties

All disclosed owners & managing parties 3

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Christina a Graham Individual Corporate OfficerChief Financial Officer Oct 1, 2023
W-2 Managing EmployeeChief Financial Officer Oct 1, 2023
East Tennessee State University Organization, Johnson City, TN 5% Or Greater Direct Ownership Interest Jan 2, 2008 100%
Operational/Managerial Control Jan 2, 2008 100%
Ashley P McBee Individual Corporate Officer Oct 1, 2023
W-2 Managing Employee Oct 1, 2023

Owners & managing parties with NPI records 3

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

  • East Tennessee State University

    dba Hancock County High School Based Health Center

    • Federally Qualified Health Center (FQHC)
    • Sneedville, TN
    • NPI 1215045976

    5% Or Greater Direct Ownership Interest, Operational/Managerial Control

    CMS ownership
  • East Tennessee State University

    dba Hancock County Elementary School Based Health Center

    • Federally Qualified Health Center (FQHC)
    • Sneedville, TN
    • NPI 1326142563

    5% Or Greater Direct Ownership Interest, Operational/Managerial Control

    CMS ownership
  • East Tennessee State University

    dba Johnson City Community Health Center

    • Federally Qualified Health Center (FQHC)
    • Johnson City, TN
    • NPI 1477660199

    5% Or Greater Direct Ownership Interest, Operational/Managerial Control

    CMS ownership

All facility ownership & control disclosures 2

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Johnson City Community Health CenterJohnson City, TN, CCN 441901 Federally qualified health center 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control (100%)		 Mar 26, 1990
Mar 26, 1990
Hancock County Middle/High School Based Health CenterSneedville, TN, CCN 441894 Federally qualified health center 5% Or Greater Direct Ownership Interest (100%) Apr 8, 1998

Owned or controlled facilities with NPI records 2

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

  • East Tennessee State University

    dba Hancock County High School Based Health Center

    • Federally Qualified Health Center (FQHC)
    • Sneedville, TN
    • NPI 1215045976

    5% Or Greater Direct Ownership Interest

    CMS ownership
  • East Tennessee State University

    dba Johnson City Community Health Center

    • Federally Qualified Health Center (FQHC)
    • Johnson City, TN
    • NPI 1477660199

    5% Or Greater Direct Ownership Interest, Operational/Managerial Control

    CMS ownership

Facilities with the same owner 2

Facilities that share an organizational owner with 5% or greater ownership or operational control.

Practitioners & affiliated clinicians

Practitioners 59

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 59

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1199232000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1658361600000",
    "number": "1093990608",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "365 STOUT DRIVE BOX 70403",
            "city": "JOHNSON CITY",
            "state": "TN",
            "postal_code": "376141703",
            "telephone_number": "423-439-4515",
            "fax_number": "423-439-5780"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "202 W FAIRVIEW AVE",
            "city": "JOHNSON CITY",
            "state": "TN",
            "postal_code": "376045611",
            "telephone_number": "423-434-0894",
            "fax_number": "423-434-0666"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EAST TENNESSEE STATE UNIVERSITY",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-01-02",
        "last_updated": "2022-07-21",
        "status": "A",
        "authorized_official_last_name": "KING",
        "authorized_official_first_name": "BETTY",
        "authorized_official_middle_name": "J.",
        "authorized_official_title_or_position": "ACTING CHIEF FINANCIAL OFFICER",
        "authorized_official_telephone_number": "423-439-4414"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Johnson City Downtown Clinic Day Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Johnson City, TN

Sources for this page

Verify at the official NPI Registry.