Provider Demographics
NPI:1518503804
Name:WT REGIONAL MEDICAL ASSOCIATES
Entity Type:Organization
Organization Name:WT REGIONAL MEDICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BARTLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:TEAGUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:731-512-1277
Mailing Address - Street 1:1804 HIGHWAY 45 BYP STE 604
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-4403
Mailing Address - Country:US
Mailing Address - Phone:731-660-8759
Mailing Address - Fax:731-660-8739
Practice Address - Street 1:108 W 15TH ST
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:573-333-0033
Practice Address - Fax:573-333-2522
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JACKSON-MADISON COUNTY GENERAL HOSPITAL DISTRICT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-11-21
Last Update Date:2019-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty