Provider Demographics
NPI:1649770769
Name:FAST PACE MEDICAL CLINIC PLLC
Entity Type:Organization
Organization Name:FAST PACE MEDICAL CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:BENSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:931-253-1110
Mailing Address - Street 1:PO BOX 1258
Mailing Address - Street 2:
Mailing Address - City:WAYNESBORO
Mailing Address - State:TN
Mailing Address - Zip Code:38485-1258
Mailing Address - Country:US
Mailing Address - Phone:931-253-1110
Mailing Address - Fax:931-722-9919
Practice Address - Street 1:4152 W STATE ROAD
Practice Address - Street 2:
Practice Address - City:HANOVER
Practice Address - State:IN
Practice Address - Zip Code:47243
Practice Address - Country:US
Practice Address - Phone:931-253-1110
Practice Address - Fax:931-722-9919
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-15
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300036022Medicaid