1124116454 NPI number — MCEWEN FAMILY CLINIC PLLC

Table of content: (NPI 1124116454)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124116454 NPI number — MCEWEN FAMILY CLINIC PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MCEWEN FAMILY CLINIC PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124116454
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/21/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 306
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MC EWEN
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37101-0306
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
931-582-6681
Provider Business Mailing Address Fax Number:
931-582-3758

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9307 HWY 70 EAST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MCEWEN
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37101
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
931-582-6681
Provider Business Practice Location Address Fax Number:
931-582-3758
Provider Enumeration Date:
10/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
YANCEY
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
WARREN
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
931-582-6681

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3733088 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com