Provider Demographics
NPI:1346250644
Name:FAMILY MEDICINE OF JONESBOROUGH LLC
Entity Type:Organization
Organization Name:FAMILY MEDICINE OF JONESBOROUGH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:JEWETT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:423-788-0123
Mailing Address - Street 1:806 E JACKSON BLVD
Mailing Address - Street 2:SUITE 8
Mailing Address - City:JONESBOROUGH
Mailing Address - State:TN
Mailing Address - Zip Code:37659-1546
Mailing Address - Country:US
Mailing Address - Phone:423-788-0123
Mailing Address - Fax:423-788-0124
Practice Address - Street 1:806 E JACKSON BLVD
Practice Address - Street 2:SUITE 8
Practice Address - City:JONESBOROUGH
Practice Address - State:TN
Practice Address - Zip Code:37659-1546
Practice Address - Country:US
Practice Address - Phone:423-788-0123
Practice Address - Fax:423-788-0124
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3735554Medicaid
TN3735554Medicare ID - Type Unspecified