Provider Demographics
NPI:1275567125
Name:MOBILE MEDICAL CLINIC PLLC
Entity Type:Organization
Organization Name:MOBILE MEDICAL CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:E
Authorized Official - Last Name:DEAN
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:615-449-7002
Mailing Address - Street 1:PO BOX 158
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:TN
Mailing Address - Zip Code:37088-0158
Mailing Address - Country:US
Mailing Address - Phone:615-449-7002
Mailing Address - Fax:
Practice Address - Street 1:404 CASTLE HEIGHTS AVE N
Practice Address - Street 2:SUITE E
Practice Address - City:LEBANON
Practice Address - State:TN
Practice Address - Zip Code:37087-1511
Practice Address - Country:US
Practice Address - Phone:615-449-7002
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3907834Medicaid
TN3907834Medicare PIN