Provider Demographics
NPI:1346397064
Name:MAGNUSON-STIMPSON MEDICAL CLINIC
Entity Type:Organization
Organization Name:MAGNUSON-STIMPSON MEDICAL CLINIC
Other - Org Name:MAGNUSON-STIMPSON MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:GENERAL PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:L
Authorized Official - Last Name:MAGNUSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:931-685-4060
Mailing Address - Street 1:1701 N MAIN ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:SHELBYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37160-2303
Mailing Address - Country:US
Mailing Address - Phone:931-685-4060
Mailing Address - Fax:931-685-4062
Practice Address - Street 1:1701 N MAIN ST
Practice Address - Street 2:SUITE D
Practice Address - City:SHELBYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37160-2303
Practice Address - Country:US
Practice Address - Phone:931-685-4060
Practice Address - Fax:931-685-4062
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-04
Last Update Date:2010-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD15929207Q00000X
TNMD19528208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3719310Medicaid
TN=========OtherOTHER INSURANCE - EIN
TN3719310Medicare PIN