Basic Information
| Provider Information | |||||||||
| NPI: | 1427199819 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AMBULATORY CARE CENTER OF WARTBURG PRIMARY CARE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 368 | ||||||||
| Address2: | |||||||||
| City: | WARTBURG | ||||||||
| State: | TN | ||||||||
| PostalCode: | 378870368 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4233465566 | ||||||||
| FaxNumber: | 4233465631 | ||||||||
| Practice Location | |||||||||
| Address1: | 1236 KNOXVILLE HWY | ||||||||
| Address2: | |||||||||
| City: | WARTBURG | ||||||||
| State: | TN | ||||||||
| PostalCode: | 378874200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4233465566 | ||||||||
| FaxNumber: | 4233465631 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2007 | ||||||||
| LastUpdateDate: | 04/15/2010 | ||||||||
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| AuthorizedOfficialLastName: | REDMON | ||||||||
| AuthorizedOfficialFirstName: | ERIC | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4233465566 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 3721832 | 05 | TN | MEDICAID |