NPIMap

Organization Active NPI

East Tennessee Brain & Spine Center, PC

  • Neurological Surgery Physician
  • Johnson City, TN
National Provider Identifier
1366452914
Registry record updated Jun 6, 2012
On this page

Key facts

NPPES NPI Registry
Primary specialty
Neurological Surgery PhysicianTaxonomy code 207T00000X
Legal business name
EAST TENNESSEE BRAIN & SPINE CENTER, PC
Practice address
701 Med Tech Pkwy
Suite 300
Johnson City, TN 37604-2365
Phone
(423) 232-8301
Fax
(423) 232-8304
NPI assigned
Aug 8, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 6, 2012

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

Authorized official

Name
Dr. David A. Wiles, MD
Title
President
Phone
(423) 232-8301

Specialties & licenses 4

Specialty (taxonomy)CodeLicenseStatePrimary
Neurological Surgery PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207T00000X TN Primary
Surgical Physician AssistantGroup: 193200000X MULTI-SPECIALTY GROUP 363AS0400X TN
Adult Health Nurse PractitionerGroup: 193200000X MULTI-SPECIALTY GROUP 363LA2200X
Family Nurse PractitionerGroup: 193200000X MULTI-SPECIALTY GROUP 363LF0000X

Addresses

Primary practice location

701 Med Tech Pkwy
Suite 300
Johnson City, TN 37604-2365

Mailing address

PO Box 9150
Paducah, KY 42002-9150
Phone (270) 744-9600

Other identifiers 5

IdentifierTypeStateIssuer
4069221OtherTNBLUE CROSS/BLUE SHIELD
3721061MedicaidTN
1366452914MedicaidVA
5903904MedicaidNC
7100132610MedicaidKY

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 8

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.

NPI Registry JSON

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

{
    "created_epoch": "1154995200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1338940800000",
    "number": "1366452914",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 9150",
            "city": "PADUCAH",
            "state": "KY",
            "postal_code": "420029150",
            "telephone_number": "270-744-9600",
            "fax_number": "270-744-0834"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "701 MED TECH PKWY",
            "address_2": "SUITE 300",
            "city": "JOHNSON CITY",
            "state": "TN",
            "postal_code": "376042365",
            "telephone_number": "423-232-8301",
            "fax_number": "423-232-8304"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EAST TENNESSEE BRAIN & SPINE CENTER, PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-08-08",
        "last_updated": "2012-06-06",
        "status": "A",
        "authorized_official_last_name": "WILES",
        "authorized_official_first_name": "DAVID",
        "authorized_official_middle_name": "A.",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "423-232-8301",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "207T00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Neurological Surgery",
            "state": "TN",
            "license": null,
            "primary": true
        },
        {
            "code": "363AS0400X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Physician Assistant, Surgical",
            "state": "TN",
            "license": null,
            "primary": false
        },
        {
            "code": "363LA2200X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner, Adult Health",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363LF0000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner, Family",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS/BLUE SHIELD",
            "identifier": "4069221",
            "state": "TN"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "3721061",
            "state": "TN"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1366452914",
            "state": "VA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "5903904",
            "state": "NC"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "7100132610",
            "state": "KY"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Johnson City, TN

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 6, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.