Provider Demographics
NPI:1437703741
Name:PROVIDENCE FAMILY MEDICINE
Entity Type:Organization
Organization Name:PROVIDENCE FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATINA
Authorized Official - Middle Name:E
Authorized Official - Last Name:HUFF
Authorized Official - Suffix:
Authorized Official - Credentials:PAC
Authorized Official - Phone:931-836-3262
Mailing Address - Street 1:287 W TURN TABLE RD
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:TN
Mailing Address - Zip Code:38583-1366
Mailing Address - Country:US
Mailing Address - Phone:931-836-3262
Mailing Address - Fax:931-836-3269
Practice Address - Street 1:287 W TURN TABLE RD
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:TN
Practice Address - Zip Code:38583-1366
Practice Address - Country:US
Practice Address - Phone:931-836-3262
Practice Address - Fax:931-836-3269
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-25
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1529553Medicaid