Provider Demographics
NPI:1053300079
Name:THE FAMILY PRACTICE CENTER PC
Entity Type:Organization
Organization Name:THE FAMILY PRACTICE CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/DOCTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:H
Authorized Official - Last Name:MCCONNELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:423-623-6240
Mailing Address - Street 1:407 4TH ST
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37821-3755
Mailing Address - Country:US
Mailing Address - Phone:423-623-6240
Mailing Address - Fax:423-623-0102
Practice Address - Street 1:407 4TH ST
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:TN
Practice Address - Zip Code:37821-3755
Practice Address - Country:US
Practice Address - Phone:423-623-6240
Practice Address - Fax:423-623-0102
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNMD7410OtherMEDICAL LIC - AJG
TNTN5602OtherMEDICAL LIC - DHMC
TNMD11046OtherMEDICAL LIC - MTH
TNMD17859OtherMEDICAL LIC - DJK
TNMD35295OtherMEDICAL LIC - JAB
TN338449Medicaid
TNMD16178OtherMEDICAL LIC - KLH
A99269Medicare UPIN
TNMD17859OtherMEDICAL LIC - DJK
3187867Medicare ID - Type UnspecifiedMICHAEL T HOOD
H41663Medicare UPIN
TN338449Medicaid
TNMD11046OtherMEDICAL LIC - MTH
D32069Medicare UPIN
338449Medicare ID - Type Unspecified
TNMD7410OtherMEDICAL LIC - AJG
TNMD35295OtherMEDICAL LIC - JAB
3028743Medicare ID - Type UnspecifiedDAVID J KICKLLTER
3012711Medicare ID - Type UnspecifiedKENNETH L HILL
3864832Medicare ID - Type UnspecifiedJOSEPH A BROMBACH