Basic Information
| Provider Information | |||||||||
| NPI: | 1346381878 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DOCTORS' CLINIC OF UNION CITY, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1020 REELFOOT AVE | ||||||||
| Address2: | |||||||||
| City: | UNION CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 382615801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7318855131 | ||||||||
| FaxNumber: | 7318855335 | ||||||||
| Practice Location | |||||||||
| Address1: | 1020 REELFOOT AVE | ||||||||
| Address2: | |||||||||
| City: | UNION CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 382615801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7318855131 | ||||||||
| FaxNumber: | 7318855335 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2007 | ||||||||
| LastUpdateDate: | 05/17/2010 | ||||||||
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| AuthorizedOfficialLastName: | BRADBERRY | ||||||||
| AuthorizedOfficialFirstName: | SAMUEL | ||||||||
| AuthorizedOfficialMiddleName: | W. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7318855131 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3375259 | 05 | TN | MEDICAID |