Provider Demographics
NPI:1417001645
Name:TAZEWELL MEDICAL CLINIC, INC.
Entity Type:Organization
Organization Name:TAZEWELL MEDICAL CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RONDAL
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:BROCK
Authorized Official - Suffix:
Authorized Official - Credentials:PAC
Authorized Official - Phone:423-626-6145
Mailing Address - Street 1:1442 N BROAD ST
Mailing Address - Street 2:SUITE 7
Mailing Address - City:TAZEWELL
Mailing Address - State:TN
Mailing Address - Zip Code:37879-4361
Mailing Address - Country:US
Mailing Address - Phone:423-626-6145
Mailing Address - Fax:423-526-2804
Practice Address - Street 1:1442 N BROAD ST
Practice Address - Street 2:SUITE 7
Practice Address - City:TAZEWELL
Practice Address - State:TN
Practice Address - Zip Code:37879-4361
Practice Address - Country:US
Practice Address - Phone:423-626-6145
Practice Address - Fax:423-526-2804
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA476261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4043299OtherBCBS-T GROUP NUMBER
3718715Medicare ID - Type UnspecifiedCLINIC MEDICARE NUMBER
TN3718715Medicare ID - Type Unspecified