Basic Information
| Provider Information | |||||||||
| NPI: | 1851835367 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WEST TENNESSEE MEDICAL GROUP INC | ||||||||
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| OtherOrganizationName: | PRIME CARE MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1804 HIGHWAY 45 BYP | ||||||||
| Address2: | SUITE 604 | ||||||||
| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383054436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7315415000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 270 E COURT AVE | ||||||||
| Address2: | SUITE B | ||||||||
| City: | SELMER | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383752304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7316457932 | ||||||||
| FaxNumber: | 7316455195 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2016 | ||||||||
| LastUpdateDate: | 01/07/2017 | ||||||||
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| AuthorizedOfficialLastName: | ROSS | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7315415000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.