Provider Demographics
NPI:1629586375
Name:WADE FAMILY MEDICINE, LLC.
Entity Type:Organization
Organization Name:WADE FAMILY MEDICINE, LLC.
Other - Org Name:WADE FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FNP
Authorized Official - Prefix:
Authorized Official - First Name:MODEANNA
Authorized Official - Middle Name:LEIGH
Authorized Official - Last Name:WADE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-244-4648
Mailing Address - Street 1:115 S MUNFORD ST
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:TN
Mailing Address - Zip Code:38019-2527
Mailing Address - Country:US
Mailing Address - Phone:901-244-4646
Mailing Address - Fax:
Practice Address - Street 1:899 HIGHWAY 51 S
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:TN
Practice Address - Zip Code:38019-2568
Practice Address - Country:US
Practice Address - Phone:901-244-4646
Practice Address - Fax:901-244-4647
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-16
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261Q00000X, 261QM1300X, 261QP2300X, 363L00000X
TN16204261QP2300X, 261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1525986Medicaid