Basic Information
| Provider Information | |||||||||
| NPI: | 1477870467 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WT REGIONAL MEDICAL ASSOCIATES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WEST TENNESSEE MEDICAL GROUP PRIMARY CARE CARUTHERSVILLE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 108 W 15TH STREET | ||||||||
| Address2: | |||||||||
| City: | CARUTHERSVILLE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 638302202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733330033 | ||||||||
| FaxNumber: | 5733332522 | ||||||||
| Practice Location | |||||||||
| Address1: | 108 W 15TH STREET | ||||||||
| Address2: | |||||||||
| City: | CARUTHERSVILLE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 638302202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7315121277 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/29/2010 | ||||||||
| LastUpdateDate: | 01/03/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ROSS | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7315416735 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | PRESIDENT | ||||||||
| NPICertificationDate: | 01/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 079-3800 | 05 | MO | MEDICAID |