Basic Information
| Provider Information | |||||||||
| NPI: | 1649523739 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MCNAIRY HOSPITAL CORPORATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | TENNOVA FAMILY MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 689022 | ||||||||
| Address2: | |||||||||
| City: | FRANKLIN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370689022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8007097338 | ||||||||
| FaxNumber: | 6154696505 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 PHYSICIANS DR | ||||||||
| Address2: | |||||||||
| City: | SELMER | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383751887 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7316456777 | ||||||||
| FaxNumber: | 7316461333 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2012 | ||||||||
| LastUpdateDate: | 08/24/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HOLTSFORD | ||||||||
| AuthorizedOfficialFirstName: | LAURIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 6154657466 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | 0000000081 | TN | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 0443445 | 05 | TN | MEDICAID |