Basic Information
Provider Information | |||||||||
NPI: | 1548211550 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | FAMILY HEALTH GROUP INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
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: | 854 W JAMES CAMPBELL BLVD | ||||||||
Address2: | SUITE 301 | ||||||||
City: | COLUMBIA | ||||||||
State: | TN | ||||||||
PostalCode: | 384014659 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9313888779 | ||||||||
FaxNumber: | 9315400518 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/15/2006 | ||||||||
LastUpdateDate: | 06/10/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PRESTON | ||||||||
AuthorizedOfficialFirstName: | HAROLD | ||||||||
AuthorizedOfficialMiddleName: | E | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 9315404255 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363A00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   | 207R00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 3710088 | 05 | TN |   | MEDICAID |