Provider Demographics
NPI:1366485682
Name:WEST TENNESSEE NEUROSURGICAL CLINIC
Entity Type:Organization
Organization Name:WEST TENNESSEE NEUROSURGICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:W
Authorized Official - Last Name:NEBLETT
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:731-410-2367
Mailing Address - Street 1:1040 GREYSTONE SQ
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-3580
Mailing Address - Country:US
Mailing Address - Phone:731-410-2367
Mailing Address - Fax:731-668-8487
Practice Address - Street 1:1040 GREYSTONE SQ
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-3580
Practice Address - Country:US
Practice Address - Phone:731-410-2367
Practice Address - Fax:731-668-8487
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-14
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3710575Medicaid
TN4052871OtherBLUE CROSS BLUE SHIELD
TN3710575Medicare ID - Type Unspecified
DA0836Medicare ID - Type UnspecifiedRAILROAD MEDICARE