Basic Information
| Provider Information | |||||||||
| NPI: | 1184959207 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WEST TENNESSEE MEDICAL GROUP INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MEDSOUTH MEDICAL CLINIC DYERSBURG | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3669 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383033669 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7316608759 | ||||||||
| FaxNumber: | 7316608739 | ||||||||
| Practice Location | |||||||||
| Address1: | 1700 WOODLAWN AVE | ||||||||
| Address2: | |||||||||
| City: | DYERSBURG | ||||||||
| State: | TN | ||||||||
| PostalCode: | 380242028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7312874547 | ||||||||
| FaxNumber: | 7312874804 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2009 | ||||||||
| LastUpdateDate: | 09/13/2011 | ||||||||
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| AuthorizedOfficialLastName: | PHILLIPS | ||||||||
| AuthorizedOfficialFirstName: | JAMA | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7315121510 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | JACKSON MADISON COUNTY GENERAL HOSPITAL DISTRICT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.