1053300079 NPI number — THE FAMILY PRACTICE CENTER PC

Table of content: (NPI 1053300079)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053300079 NPI number — THE FAMILY PRACTICE CENTER PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE FAMILY PRACTICE CENTER PC
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:
1053300079
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
407 4TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEWPORT
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37821-3755
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-623-6240
Provider Business Mailing Address Fax Number:
423-623-0102

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
407 4TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEWPORT
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37821-3755
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-623-6240
Provider Business Practice Location Address Fax Number:
423-623-0102
Provider Enumeration Date:
10/21/2005

Additional Information

Authorized Official

Authorized Official Last Name:
MCCONNELL
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
H
Authorized Official Title or Position:
PRESIDENT/DOCTOR
Authorized Official Telephone Number:
423-623-6240

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: MD7410 . This is a "MEDICAL LIC - AJG" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: TN5602 . This is a "MEDICAL LIC - DHMC" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: MD11046 . This is a "MEDICAL LIC - MTH" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: MD17859 . This is a "MEDICAL LIC - DJK" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: MD35295 . This is a "MEDICAL LIC - JAB" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 338449 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: MD16178 . This is a "MEDICAL LIC - KLH" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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