Basic Information
Provider Information | |||||||||
NPI: | 1518503804 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WT REGIONAL MEDICAL ASSOCIATES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
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 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | TEAGUE | ||||||||
AuthorizedOfficialFirstName: | BARTLEY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 7315121277 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | JACKSON-MADISON COUNTY GENERAL HOSPITAL DISTRICT | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
No ID Information.