Basic Information
| Provider Information | |||||||||
| NPI: | 1528300621 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FAMILY HEALTH GROUP INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FAMILY HEALTH GROUP INC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 854 W JAMES CAMPBELL BLVD | ||||||||
| Address2: | SUITE 303 | ||||||||
| City: | COLUMBIA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 384014659 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9315404255 | ||||||||
| FaxNumber: | 9314904654 | ||||||||
| Practice Location | |||||||||
| Address1: | 1218 TROTWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 384016406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9313804114 | ||||||||
| FaxNumber: | 9313807106 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2013 | ||||||||
| LastUpdateDate: | 05/02/2013 | ||||||||
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| AuthorizedOfficialLastName: | COOK | ||||||||
| AuthorizedOfficialFirstName: | CATHERINE | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 9315404255 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FAMILY HEALTH GROUP INC | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
ID Information
| ID | Type | State | Issuer | Description | 3710089 | 05 | TN | MEDICAID |