Provider Demographics
NPI:1023180478
Name:WEST CLINIC PC
Entity Type:Organization
Organization Name:WEST CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:O
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-683-0055
Mailing Address - Street 1:100 N HUMPHREYS BLVD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-2146
Mailing Address - Country:US
Mailing Address - Phone:901-683-0055
Mailing Address - Fax:901-685-2969
Practice Address - Street 1:1500 W POPLAR AVE
Practice Address - Street 2:SUITE 304
Practice Address - City:COLLIERVILLE
Practice Address - State:TN
Practice Address - Zip Code:38017-0601
Practice Address - Country:US
Practice Address - Phone:901-850-1456
Practice Address - Fax:901-850-5830
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0106442OtherBCBS TN
AR132175002Medicaid
AR8P003OtherBCBS AR
TN3704066Medicaid
MS09013755Medicaid
MO500557509Medicaid
AR132175002Medicaid
MO500557509Medicaid
MS09013755Medicaid