Provider Demographics
NPI:1871361436
Name:EAST TENNESSEE ADDICTION SPECIALISTS
Entity type:Organization
Organization Name:EAST TENNESSEE ADDICTION SPECIALISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CLAY
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:STALCUP
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:865-406-2715
Mailing Address - Street 1:2036 CHILHOWEE MEDICAL PARK
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37804-5285
Mailing Address - Country:US
Mailing Address - Phone:865-268-4360
Mailing Address - Fax:
Practice Address - Street 1:20445 ALBERTA ST
Practice Address - Street 2:
Practice Address - City:ONEIDA
Practice Address - State:TN
Practice Address - Zip Code:37841-3509
Practice Address - Country:US
Practice Address - Phone:423-286-7638
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-13
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use DisorderGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ045176Medicaid