Provider Demographics
NPI:1508824749
Name:SOUTHERN MEDICAL CLINICS, LLC
Entity Type:Organization
Organization Name:SOUTHERN MEDICAL CLINICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:CHIN
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:423-728-1845
Mailing Address - Street 1:PO BOX 2515
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37320-2515
Mailing Address - Country:US
Mailing Address - Phone:423-728-1845
Mailing Address - Fax:423-728-1925
Practice Address - Street 1:2384 BLUE SPRINGS RD SE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37311-0909
Practice Address - Country:US
Practice Address - Phone:423-728-1845
Practice Address - Fax:423-728-1925
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-03
Last Update Date:2014-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD31732261QP2300X
TNPA753363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNH32583Medicare UPIN
TNS77380Medicare UPIN