Provider Demographics
NPI:1629494786
Name:ALLIANCE MEDICAL CLINIC PC
Entity Type:Organization
Organization Name:ALLIANCE MEDICAL CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARIANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:FORSYTHE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:731-512-0104
Mailing Address - Street 1:21 MERIDIAN SPRINGS DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38301-5900
Mailing Address - Country:US
Mailing Address - Phone:731-421-8088
Mailing Address - Fax:731-421-8091
Practice Address - Street 1:21 MERIDIAN SPRINGS DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-5900
Practice Address - Country:US
Practice Address - Phone:731-421-8088
Practice Address - Fax:731-421-8091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-13
Last Update Date:2014-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN6012010OtherBCBST
TNQ004761Medicaid
TN6012010OtherBCBST