1508916206 NPI number — BROWNSVILLE MEDICAL CLINIC, P.A.

Table of content: (NPI 1508916206)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508916206 NPI number — BROWNSVILLE MEDICAL CLINIC, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BROWNSVILLE MEDICAL CLINIC, P.A.
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:
OLD HICKORY FAMILY MEDICINE
Provider Other Organization Name Type Code:
3
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:
1508916206
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/09/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3363 N HIGHLAND AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSON
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38305-3487
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
731-660-6828
Provider Business Mailing Address Fax Number:
731-660-6820

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3363 N HIGHLAND AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38305-3487
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
731-660-6828
Provider Business Practice Location Address Fax Number:
731-660-6820
Provider Enumeration Date:
01/12/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
WHITE
Authorized Official First Name:
CLAUDIA
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
731-660-6828

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QP2300X , with the licence number: MD8895 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 3386790 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3156270 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".