East Tennessee Dialysis Center Inc

Primary specialty

End-Stage Renal Disease (ESRD) Treatment Clinic/CenterTaxonomy code 261QE0700X

License

0000000124 Issued in TN

Legal business name

EAST TENNESSEE DIALYSIS CENTER INC

Practice address

1629 E Broadway Ave
Maryville, TN 37804-2913

Phone

(865) 681-2900

Fax

(865) 980-0907

NPI assigned

Mar 5, 2007

Organization subpart

No

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

Authorized official

Name

Mr. Moeen A Hatab, PHD

Title

Administrator

Phone

(865) 681-2900

Specialties & licenses 1

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

End-stage renal disease facility certification: CCN 442726

Legal name

(CLOSED) EAST TENNESSEE DIALYSIS CENTER, INC

Certification status

Active

Provider type (POS)

End-stage renal disease facility

Participating since

Jan 26, 2015

Last certification

May 8, 2019

Ownership / control type

For Profit

Facility address

1629 East Broadway Avenue
Maryville, TN 37804

Locations

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

{
    "created_epoch": "1173052800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1326931200000",
    "number": "1467581744",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 32094",
            "city": "KNOXVILLE",
            "state": "TN",
            "postal_code": "37930",
            "telephone_number": "865-681-2900",
            "fax_number": "865-980-0907"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1629 E BROADWAY AVE",
            "city": "MARYVILLE",
            "state": "TN",
            "postal_code": "378042913",
            "telephone_number": "865-681-2900",
            "fax_number": "865-980-0907"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EAST TENNESSEE DIALYSIS CENTER INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-03-05",
        "last_updated": "2012-01-19",
        "status": "A",
        "authorized_official_last_name": "HATAB",
        "authorized_official_first_name": "MOEEN",
        "authorized_official_middle_name": "A",
        "authorized_official_title_or_position": "ADMINISTRATOR",
        "authorized_official_telephone_number": "865-681-2900",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "PHD"
    },
    "taxonomies": [
        {
            "code": "261QE0700X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, End-Stage Renal Disease (ESRD) Treatment",
            "state": "TN",
            "license": "0000000124",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0442636",
            "state": "TN"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• East Tennessee Foot Clinic PC
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• Cynthia J Easter, M.D.
• Easterly Family Medicine

• End-Stage Renal Disease (ESRD) Treatment Clinic/Center in Maryville, TN
• Providers in Maryville, TN by specialty
• End-Stage Renal Disease (ESRD) Treatment Clinic/Center in Tennessee

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 19, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; facility enrollments, owners and changes of ownership; Provider of Services certification data.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.