Provider Demographics
NPI:1477870467
Name:WT REGIONAL MEDICAL ASSOCIATES
Entity Type:Organization
Organization Name:WT REGIONAL MEDICAL ASSOCIATES
Other - Org Name:WEST TENNESSEE MEDICAL GROUP PRIMARY CARE CARUTHERSVILLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:E
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:
Authorized Official - Credentials:PRESIDENT
Authorized Official - Phone:731-541-6735
Mailing Address - Street 1:108 W 15TH STREET
Mailing Address - Street 2:
Mailing Address - City:CARUTHERSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63830-2202
Mailing Address - Country:US
Mailing Address - Phone:573-333-0033
Mailing Address - Fax:573-333-2522
Practice Address - Street 1:108 W 15TH STREET
Practice Address - Street 2:
Practice Address - City:CARUTHERSVILLE
Practice Address - State:MO
Practice Address - Zip Code:63830-2202
Practice Address - Country:US
Practice Address - Phone:731-512-1277
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-29
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO079-3800Medicaid