Provider Demographics
NPI:1568499499
Name:WOMENS CLINIC OF DYERSBURG, PLLC
Entity Type:Organization
Organization Name:WOMENS CLINIC OF DYERSBURG, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:D
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:731-286-1319
Mailing Address - Street 1:1410 INDUSTRIAL PARK ROAD
Mailing Address - Street 2:
Mailing Address - City:PARIS
Mailing Address - State:TN
Mailing Address - Zip Code:38242
Mailing Address - Country:US
Mailing Address - Phone:800-887-4359
Mailing Address - Fax:800-555-0119
Practice Address - Street 1:305 E TICKLE ST
Practice Address - Street 2:SUITE B
Practice Address - City:DYERSBURG
Practice Address - State:TN
Practice Address - Zip Code:38024-3117
Practice Address - Country:US
Practice Address - Phone:731-286-1319
Practice Address - Fax:731-287-0420
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-27
Last Update Date:2013-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNDC8704OtherRAILROAD MEDICARE
TNDC8704Medicare PIN
TN3728110Medicare PIN