Basic Information
Provider Information | |||||||||
NPI: | 1750688479 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WEST TENNESSEE MEDICAL GROUP, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MEDSOUTH MEDICAL CENTER, DYERSBURG | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1700 WOODLAWN AVE | ||||||||
Address2: |   | ||||||||
City: | DYERSBURG | ||||||||
State: | TN | ||||||||
PostalCode: | 380242028 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7312874500 | ||||||||
FaxNumber: | 7312874804 | ||||||||
Practice Location | |||||||||
Address1: | 1700 WOODLAWN AVE | ||||||||
Address2: |   | ||||||||
City: | DYERSBURG | ||||||||
State: | TN | ||||||||
PostalCode: | 380242028 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7312874500 | ||||||||
FaxNumber: | 7312874804 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/15/2011 | ||||||||
LastUpdateDate: | 04/29/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ROSS | ||||||||
AuthorizedOfficialFirstName: | JAMES | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | INTERIM PRESIDENT AND CEO | ||||||||
AuthorizedOfficialTelephone: | 7315416730 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | WEST TENNESSEE MEDICAL GROUP, INC | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center |   |
No ID Information.