Provider Demographics
NPI:1407952799
Name:WHITE BLUFF FAMILY HEALTH CARE CENTER INC
Entity Type:Organization
Organization Name:WHITE BLUFF FAMILY HEALTH CARE CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWIN
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMON
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:615-797-3646
Mailing Address - Street 1:PO BOX 624
Mailing Address - Street 2:
Mailing Address - City:GOODLETTSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37070-0624
Mailing Address - Country:US
Mailing Address - Phone:615-797-3646
Mailing Address - Fax:615-797-4055
Practice Address - Street 1:2004 HIGHWAY 47 NORTH
Practice Address - Street 2:
Practice Address - City:WHITE BLUFF
Practice Address - State:TN
Practice Address - Zip Code:37187
Practice Address - Country:US
Practice Address - Phone:615-797-3646
Practice Address - Fax:615-797-4055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-15
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN93835207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3711042Medicaid
TN3711042Medicaid