Provider Demographics
NPI:1083963946
Name:WEST TENNESSEE PHYSICAL MEDICINE, PLLC
Entity Type:Organization
Organization Name:WEST TENNESSEE PHYSICAL MEDICINE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:DUSTIN
Authorized Official - Last Name:FORRESTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:731-644-9000
Mailing Address - Street 1:1024 MINERAL WELLS AVENUE
Mailing Address - Street 2:
Mailing Address - City:PARIS
Mailing Address - State:TN
Mailing Address - Zip Code:38242
Mailing Address - Country:US
Mailing Address - Phone:731-644-9000
Mailing Address - Fax:731-644-9006
Practice Address - Street 1:1024 MINERAL WELLS AVENUE
Practice Address - Street 2:
Practice Address - City:PARIS
Practice Address - State:TN
Practice Address - Zip Code:38242
Practice Address - Country:US
Practice Address - Phone:731-644-9000
Practice Address - Fax:731-644-9006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-06
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000027058208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty