Provider Demographics
NPI:1245419043
Name:COMPREHENSIVE PRIMARY CARE PLLC
Entity Type:Organization
Organization Name:COMPREHENSIVE PRIMARY CARE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:CLAY
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:901-840-1202
Mailing Address - Street 1:76 CAPITAL WAY
Mailing Address - Street 2:SUITE C
Mailing Address - City:ATOKA
Mailing Address - State:TN
Mailing Address - Zip Code:38004-6832
Mailing Address - Country:US
Mailing Address - Phone:901-840-1202
Mailing Address - Fax:901-840-1204
Practice Address - Street 1:76 CAPITAL WAY
Practice Address - Street 2:SUITE C
Practice Address - City:ATOKA
Practice Address - State:TN
Practice Address - Zip Code:38004-6832
Practice Address - Country:US
Practice Address - Phone:901-840-1202
Practice Address - Fax:901-840-1204
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-29
Last Update Date:2013-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN31696207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN38459502Medicare PIN
TNH04663Medicare UPIN