NPIMap

Organization Active NPI

East Tennessee State University

  • Federally Qualified Health Center (FQHC)
  • Sneedville, TN
National Provider Identifier
1215045976
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
Practice address
2700 Main Street
Sneedville, TN 37869-0723
Phone
(423) 733-2819
Fax
(423) 733-8509
NPI assigned
Aug 25, 2006
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
David D. Collins
Title
Cfo, VP Finance & Administration
Phone
(423) 439-5884

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X Primary
Primary Care Nurse PractitionerGroup: 193400000X SINGLE SPECIALTY GROUP 363LP2300X

Addresses

Primary practice location

2700 Main Street
Sneedville, TN 37869-0723

Mailing address

PO Box 70403
Johnson City, TN 37614-1703
Phone (423) 439-4078

Other identifiers 1

IdentifierTypeStateIssuer
3709292MedicaidTN

Other names 1

  • Hancock County High School Based Health 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
This NPI is an additional NPI on the enrollment
Practice locations: Johnson City, TN; Sneedville, TN
O20100927000795 TN Part A Provider - Federally Qualified Health Center (FQHC) 2769394774 Practice locations: Sneedville, TN

Federally qualified health center certification: CCN 441894

Legal name
EAST TENNESSEE STATE UNIVERSITY
Doing business as
HANCOCK COUNTY MIDDLE/HIGH SCHOOL BASED HEALTH CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jan 7, 2005
Last certification
Jan 7, 2005
Ownership / control type
Non-profit – corporation
Organization structure
GovernmentNon-profit
Enrollment address
2700 Main St
Sneedville, TN 37869-3041

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
East Tennessee State University20 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

1276 Gilbreath Dr
Johnson City, TN 37614
Phone (423) 439-1000

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 OfficerCfo Oct 1, 2023
W-2 Managing EmployeeCfo Oct 1, 2023
East Tennessee State University Organization, Sneedville, TN 5% Or Greater Direct Ownership Interest Apr 8, 1998 100%
Ashley P McBee Individual Corporate OfficerController Oct 1, 2023
W-2 Managing EmployeeController 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.

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
Johnson City Downtown Clinic Day CenterJohnson City, TN, CCN 441900 Federally qualified health center 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control (100%)		 Jan 2, 2008
Jan 2, 2008

Owned or controlled facilities with NPI records 2

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

Facilities with the same owner 2

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

Practitioners & affiliated clinicians

Practitioners 27

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 27

NPI Registry JSON

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

{
    "created_epoch": "1156464000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1658361600000",
    "number": "1215045976",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 70403",
            "city": "JOHNSON CITY",
            "state": "TN",
            "postal_code": "376141703",
            "telephone_number": "423-439-4078",
            "fax_number": "423-439-4060"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2700 MAIN STREET",
            "city": "SNEEDVILLE",
            "state": "TN",
            "postal_code": "378690723",
            "telephone_number": "423-733-2819",
            "fax_number": "423-733-8509"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EAST TENNESSEE STATE UNIVERSITY",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-08-25",
        "last_updated": "2022-07-21",
        "status": "A",
        "authorized_official_last_name": "COLLINS",
        "authorized_official_first_name": "DAVID",
        "authorized_official_middle_name": "D.",
        "authorized_official_title_or_position": "CFO, VP FINANCE & ADMINISTRATION",
        "authorized_official_telephone_number": "423-439-5884"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "363LP2300X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Nurse Practitioner, Primary Care",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "3709292",
            "state": "TN"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Hancock County High School Based Health Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Sneedville, TN

Sources for this page

Verify at the official NPI Registry.