Basic Information
| Provider Information | |||||||||
| NPI: | 1285746719 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CLAYTON MEDICAL CORPORATION PLC | ||||||||
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| OtherOrganizationName: | LIFETIME FAMILY CARE DBA PINEY PLUFF MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 999 EXECUTIVE PARK BLVD | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376604632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232243250 | ||||||||
| FaxNumber: | 4232243258 | ||||||||
| Practice Location | |||||||||
| Address1: | 350 BLOUNTVILLE HWY | ||||||||
| Address2: | |||||||||
| City: | BRISTOL | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376200213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4238446120 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 03/14/2008 | ||||||||
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| AuthorizedOfficialLastName: | LOCKE | ||||||||
| AuthorizedOfficialFirstName: | CINDY | ||||||||
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| AuthorizedOfficialTitleorPosition: | BILLING ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 4232243250 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CPC, CSS-P | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | MD36833 | TN | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 3723582 | 05 | TN | MEDICAID |