Basic Information
| Provider Information | |||||||||
| NPI: | 1992077077 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CLARKSVILLE PHYSICIAN SERVICES GP | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | DOVER MEDICAL CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8574 | ||||||||
| Address2: | |||||||||
| City: | BELFAST | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049158574 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8778481463 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 133 DR ROBERT H LEE DRIVE | ||||||||
| Address2: | |||||||||
| City: | DOVER | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370583750 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8883041079 | ||||||||
| FaxNumber: | 6154696629 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2012 | ||||||||
| LastUpdateDate: | 07/18/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| AuthorizedOfficialLastName: | PEOPLES | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6154657000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CLARKSVILLE PHYSICIAN SERVICES GP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 44-8914 | 01 | TN | TN-MEDICARE PART A | OTHER |