Provider Demographics
NPI:1508297367
Name:WEST SIDE MEDICAL CLINIC
Entity Type:Organization
Organization Name:WEST SIDE MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:M
Authorized Official - Last Name:SELLERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:865-862-4575
Mailing Address - Street 1:9957 KINGSTON PIKE
Mailing Address - Street 2:SUITE 105
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37922-6908
Mailing Address - Country:US
Mailing Address - Phone:865-862-4575
Mailing Address - Fax:865-909-9397
Practice Address - Street 1:9957 KINGSTON PIKE
Practice Address - Street 2:SUITE 105
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37922-6908
Practice Address - Country:US
Practice Address - Phone:865-862-4575
Practice Address - Fax:865-909-9397
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-04
Last Update Date:2014-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty