Provider Demographics
NPI:1043662687
Name:CROSSROADS CLINIC PLLC
Entity Type:Organization
Organization Name:CROSSROADS CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:VERGOT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:423-902-0681
Mailing Address - Street 1:1667 OOLTEWAH RINGGOLD RD
Mailing Address - Street 2:SUITE 111
Mailing Address - City:OOLTEWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37363-9830
Mailing Address - Country:US
Mailing Address - Phone:423-825-4881
Mailing Address - Fax:423-825-4882
Practice Address - Street 1:1667 OOLTEWAH RINGGOLD RD
Practice Address - Street 2:SUITE 111
Practice Address - City:OOLTEWAH
Practice Address - State:TN
Practice Address - Zip Code:37363-9830
Practice Address - Country:US
Practice Address - Phone:423-825-4881
Practice Address - Fax:423-825-4882
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-07
Last Update Date:2016-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty