Basic Information
| Provider Information | |||||||||
| NPI: | 1538634050 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BOLIVAR GENERAL HOSPITAL, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WEST TENNESSEE MEDICAL GROUP PRIMARY CARE BOLIVAR | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 620 SKYLINE DR | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383013923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7315121277 | ||||||||
| FaxNumber: | 7319842199 | ||||||||
| Practice Location | |||||||||
| Address1: | 640 NUCKOLLS RD | ||||||||
| Address2: | |||||||||
| City: | BOLIVAR | ||||||||
| State: | TN | ||||||||
| PostalCode: | 380081532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7316583100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2018 | ||||||||
| LastUpdateDate: | 01/22/2019 | ||||||||
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| AuthorizedOfficialLastName: | ROSS | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT AND CEO | ||||||||
| AuthorizedOfficialTelephone: | 7315121277 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BOLIVAR GENERAL HOSPITAL, INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.