Provider Demographics
NPI:1114027018
Name:DECATUR COUNTY FAMILY PRACTICE PC
Entity Type:Organization
Organization Name:DECATUR COUNTY FAMILY PRACTICE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:H
Authorized Official - Last Name:MONTGOMERY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:731-847-6010
Mailing Address - Street 1:190 UNIVERSITY AVE
Mailing Address - Street 2:PO BOX 278
Mailing Address - City:PARSONS
Mailing Address - State:TN
Mailing Address - Zip Code:38363-2972
Mailing Address - Country:US
Mailing Address - Phone:731-847-6010
Mailing Address - Fax:731-847-6011
Practice Address - Street 1:190 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:PARSONS
Practice Address - State:TN
Practice Address - Zip Code:38363-2972
Practice Address - Country:US
Practice Address - Phone:731-847-6010
Practice Address - Fax:731-847-6011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2009-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN23682207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3735206Medicaid
TN3735206Medicare PIN