Provider Demographics
NPI:1023101144
Name:EAST TENNESSEE SPINE & SPORT INC
Entity type:Organization
Organization Name:EAST TENNESSEE SPINE & SPORT INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:DEFILIPPO
Authorized Official - Suffix:
Authorized Official - Credentials:PHYSICAL THERAPIST
Authorized Official - Phone:865-689-8299
Mailing Address - Street 1:4905 N BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37918-2315
Mailing Address - Country:US
Mailing Address - Phone:865-689-8299
Mailing Address - Fax:865-689-9804
Practice Address - Street 1:150 N MARTINWOOD RD
Practice Address - Street 2:SUITE 402
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37923-5124
Practice Address - Country:US
Practice Address - Phone:865-691-5020
Practice Address - Fax:865-691-5009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3650983Medicaid
3654190Medicare ID - Type Unspecified