Basic Information
| Provider Information | |||||||||
| NPI: | 1952801334 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAST PACE MEDICAL CLINIC PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1258 | ||||||||
| Address2: | |||||||||
| City: | WAYNESBORO | ||||||||
| State: | TN | ||||||||
| PostalCode: | 384851258 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9312531110 | ||||||||
| FaxNumber: | 9317229919 | ||||||||
| Practice Location | |||||||||
| Address1: | 4152 W STATE ROAD 56 | ||||||||
| Address2: | |||||||||
| City: | HANOVER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 472439070 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8127624510 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2018 | ||||||||
| LastUpdateDate: | 07/15/2021 | ||||||||
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| AuthorizedOfficialLastName: | CLEMMONS | ||||||||
| AuthorizedOfficialFirstName: | SYDNI | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9013511791 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 07/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 05 | IN | MEDICAID |