Basic Information
| Provider Information | |||||||||
| NPI: | 1326768870 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MADISONVILLE PRIMARY CARE GROUP | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 3959 US 411 | ||||||||
| Address2: | |||||||||
| City: | MADISONVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 373541571 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234422121 | ||||||||
| FaxNumber: | 4235459556 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 W WASHINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | ATHENS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 373033468 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237456610 | ||||||||
| FaxNumber: | 4237456360 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/02/2022 | ||||||||
| LastUpdateDate: | 09/08/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CAIN | ||||||||
| AuthorizedOfficialFirstName: | GREGORY | ||||||||
| AuthorizedOfficialMiddleName: | BRIAN | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4234422121 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PA-C | ||||||||
| NPICertificationDate: | 09/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | N | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.