Provider Demographics
NPI:1154322303
Name:PERRY COUNTY MEDICAL CENTER INC
Entity Type:Organization
Organization Name:PERRY COUNTY MEDICAL CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:B
Authorized Official - Last Name:TATUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:931-589-2104
Mailing Address - Street 1:PO BOX 916
Mailing Address - Street 2:115 EAST BROOKLYN STREET
Mailing Address - City:LINDEN
Mailing Address - State:TN
Mailing Address - Zip Code:37096-0916
Mailing Address - Country:US
Mailing Address - Phone:931-589-2104
Mailing Address - Fax:931-589-2513
Practice Address - Street 1:115 E BROOKLYN ST
Practice Address - Street 2:
Practice Address - City:LINDEN
Practice Address - State:TN
Practice Address - Zip Code:37096-3515
Practice Address - Country:US
Practice Address - Phone:931-589-2104
Practice Address - Fax:931-589-2513
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-09
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3384590Medicaid
TN0443869Medicaid
TN3384590Medicaid