Basic Information
Provider Information
NPI: 1518503804
EntityType: 2
ReplacementNPI:  
OrganizationName: WT REGIONAL MEDICAL ASSOCIATES
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Mailing Information
Address1: 1804 HIGHWAY 45 BYP STE 604
Address2:  
City: JACKSON
State: TN
PostalCode: 383054403
CountryCode: US
TelephoneNumber: 7316608759
FaxNumber: 7316608739
Practice Location
Address1: 108 W 15TH ST
Address2:  
City: CARUTHERSVILLE
State: MO
PostalCode: 638302202
CountryCode: US
TelephoneNumber: 5733330033
FaxNumber: 5733332522
Other Information
ProviderEnumerationDate: 11/21/2019
LastUpdateDate: 11/21/2019
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AuthorizedOfficialLastName: TEAGUE
AuthorizedOfficialFirstName: BARTLEY
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AuthorizedOfficialTitleorPosition: EXECUTIVE DIRECTOR
AuthorizedOfficialTelephone: 7315121277
IsSoleProprietor:  
IsOrganizationSubpart: Y
ParentOrganizationLBN: JACKSON-MADISON COUNTY GENERAL HOSPITAL DISTRICT
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Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207Q00000X  Y193200000X MULTI-SPECIALTY GROUPAllopathic & Osteopathic PhysiciansFamily Medicine 

No ID Information.


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