Basic Information
| Provider Information | |||||||||
| NPI: | 1376074385 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JONESBOROUGH MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DOCTOR'S CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1003 E JACKSON BLVD STE 3 | ||||||||
| Address2: | |||||||||
| City: | JONESBOROUGH | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376591531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237536077 | ||||||||
| FaxNumber: | 4237538788 | ||||||||
| Practice Location | |||||||||
| Address1: | 2811 W MARKET ST STE 1 | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376045127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4239282135 | ||||||||
| FaxNumber: | 4239285814 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2017 | ||||||||
| LastUpdateDate: | 03/22/2017 | ||||||||
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| AuthorizedOfficialLastName: | ATYIA | ||||||||
| AuthorizedOfficialFirstName: | ATIF | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4237536077 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | JONESBOROUGH MEDICAL CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | M30739 | TN | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3874725 | 05 | TN | MEDICAID |