Basic Information
| Provider Information | |||||||||
| NPI: | 1124748512 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WEST TENNESSEE MEDICAL GROUP INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 620 SKYLINE DR | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383013923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7315415000 | ||||||||
| FaxNumber: | 7315416802 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 MARVIN DR | ||||||||
| Address2: | |||||||||
| City: | RIPLEY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 380637365 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7312213275 | ||||||||
| FaxNumber: | 7315742795 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2022 | ||||||||
| LastUpdateDate: | 08/29/2022 | ||||||||
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| AuthorizedOfficialLastName: | ROSS | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT AND CEO | ||||||||
| AuthorizedOfficialTelephone: | 7315416731 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332900000X | Y | Suppliers | Non-Pharmacy Dispensing Site |
No ID Information.