Basic Information
| Provider Information | |||||||||
| NPI: | 1184102881 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | A PATTERN MEDICAL CLINIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5545 LITTLE DEBBIE PKWY | ||||||||
| Address2: | |||||||||
| City: | OOLTEWAH | ||||||||
| State: | TN | ||||||||
| PostalCode: | 373634357 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6602290858 | ||||||||
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| Address1: | 5545 LITTLE DEBBIE PKWY | ||||||||
| Address2: | |||||||||
| City: | OOLTEWAH | ||||||||
| State: | TN | ||||||||
| PostalCode: | 373634357 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234552711 | ||||||||
| FaxNumber: | 4234654589 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2018 | ||||||||
| LastUpdateDate: | 08/27/2021 | ||||||||
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| AuthorizedOfficialLastName: | LUBERISSE | ||||||||
| AuthorizedOfficialFirstName: | ANNEX | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 6602290858 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | AL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | Q057324 | 05 | TN | MEDICAID |