Provider Demographics
NPI:1417155292
Name:TABOR FAMILY MEDICINE PLLC
Entity Type:Organization
Organization Name:TABOR FAMILY MEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:A
Authorized Official - Last Name:TABOR
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:931-526-4600
Mailing Address - Street 1:406 N WHITNEY AVE STE 3
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-4243
Mailing Address - Country:US
Mailing Address - Phone:931-537-6367
Mailing Address - Fax:931-526-4512
Practice Address - Street 1:406 N WHITNEY AVE STE 3
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-2455
Practice Address - Country:US
Practice Address - Phone:931-537-6367
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-03
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDO1379207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1417155292Medicaid