1457401416 NPI number — WEST CLINIC PC

Table of content: (NPI 1457401416)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457401416 NPI number — WEST CLINIC PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WEST CLINIC 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:
6
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:
1457401416
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/10/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 N HUMPHREYS BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MEMPHIS
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38120-2146
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
901-683-0055
Provider Business Mailing Address Fax Number:
901-322-9097

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6025 WALNUT GROVE RD
Provider Second Line Business Practice Location Address:
STE. 111
Provider Business Practice Location Address City Name:
MEMPHIS
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38120-2102
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-818-0300
Provider Business Practice Location Address Fax Number:
901-818-0458
Provider Enumeration Date:
01/11/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DAVIS
Authorized Official First Name:
RONALD
Authorized Official Middle Name:
O
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
901-683-0055

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 8P003 . This is a "BCBS" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 09015177 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: CN1272 . This is a "RAIL ROAD MEDICARE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 7100204 . This is a "AETNA" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 3704068 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: CH5373 . This is a "RAIL ROAD MEDICARE" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".




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