Provider Demographics
NPI:1629857248
Name:RED RIVER MEDICAL GROUP CORPORATION
Entity Type:Organization
Organization Name:RED RIVER MEDICAL GROUP CORPORATION
Other - Org Name:RED RIVER MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:YVETTE
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:931-368-9736
Mailing Address - Street 1:1960 MADISON ST PMB 326
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-8063
Mailing Address - Country:US
Mailing Address - Phone:931-368-9736
Mailing Address - Fax:931-346-0097
Practice Address - Street 1:1960 MADISON ST # 326
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-8063
Practice Address - Country:US
Practice Address - Phone:931-368-9736
Practice Address - Fax:931-346-0097
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-22
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty