Provider Demographics
NPI:1225073166
Name:COVENANT FAMILY PRACTICE, PC
Entity Type:Organization
Organization Name:COVENANT FAMILY PRACTICE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:931-245-1150
Mailing Address - Street 1:PO BOX 30459
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37040-0008
Mailing Address - Country:US
Mailing Address - Phone:931-245-8000
Mailing Address - Fax:931-245-0605
Practice Address - Street 1:1000 HIGHWAY 76
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-8405
Practice Address - Country:US
Practice Address - Phone:931-245-8000
Practice Address - Fax:931-245-0605
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-17
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3718348Medicaid
TN4062086OtherTN BCBS
TN3718348Medicaid