Provider Demographics
NPI:1497052104
Name:WEST TENNESSEE MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:WEST TENNESSEE MEDICAL GROUP, INC.
Other - Org Name:BRADFORD FAMILY MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:INTERIM PRESIDENT AND CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:731-541-6730
Mailing Address - Street 1:163 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRADFORD
Mailing Address - State:TN
Mailing Address - Zip Code:38316-8650
Mailing Address - Country:US
Mailing Address - Phone:731-742-2241
Mailing Address - Fax:731-742-3935
Practice Address - Street 1:163 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BRADFORD
Practice Address - State:TN
Practice Address - Zip Code:38316-8650
Practice Address - Country:US
Practice Address - Phone:731-742-2241
Practice Address - Fax:731-742-3935
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WEST TENNESSEE MEDICAL GROUP, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-02-15
Last Update Date:2016-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center