1124111356 NPI number — NORTH WILLOW FAMILY MEDICINE LLC

Table of content: (NPI 1124111356)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124111356 NPI number — NORTH WILLOW FAMILY MEDICINE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTH WILLOW FAMILY MEDICINE LLC
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:
NORTH WILLOW FAMILY MEDICINE LLC
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:
1124111356
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/02/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
428 N WILLOW AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COOKEVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38501-2339
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
931-372-7788
Provider Business Mailing Address Fax Number:
31-372-7799

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
428 N WILLOW AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COOKEVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38501-2339
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
931-372-7788
Provider Business Practice Location Address Fax Number:
31-372-7799
Provider Enumeration Date:
10/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FOX
Authorized Official First Name:
ERIC
Authorized Official Middle Name:
GREGORY
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
931-372-7788

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3883239 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4071388 . This is a "BCBS" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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