Provider Demographics
NPI:1649202102
Name:COOKEVILLE REGIONAL MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:COOKEVILLE REGIONAL MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARILYN
Authorized Official - Middle Name:C
Authorized Official - Last Name:KEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:931-783-2481
Mailing Address - Street 1:PO BOX 15060
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4045
Mailing Address - Country:US
Mailing Address - Phone:931-783-5857
Mailing Address - Fax:931-526-6760
Practice Address - Street 1:140 W 7TH ST
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-1726
Practice Address - Country:US
Practice Address - Phone:931-783-5582
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN261QM1300X, 363AS0400X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
3727506OtherMEDICARE GROUP PTAN