Basic Information
| Provider Information | |||||||||
| NPI: | 1295223279 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WT MEDICAL ASSOCIATES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1804 HIGHWAY 45 BYP STE 604 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383054403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7316608759 | ||||||||
| FaxNumber: | 7316608739 | ||||||||
| Practice Location | |||||||||
| Address1: | 1629 WOODLAWN AVE | ||||||||
| Address2: | |||||||||
| City: | DYERSBURG | ||||||||
| State: | TN | ||||||||
| PostalCode: | 38024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7315121277 | ||||||||
| FaxNumber: | 7312851440 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2018 | ||||||||
| LastUpdateDate: | 11/08/2018 | ||||||||
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| AuthorizedOfficialLastName: | TEAGUE | ||||||||
| AuthorizedOfficialFirstName: | BARTLEY | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7315121277 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | Q037006 | 05 | TN | MEDICAID |