Provider Demographics
NPI:1659364669
Name:LYNCHBURG FAMILY MEDICINE AND MINOR EMERGENCY CENTER PC
Entity Type:Organization
Organization Name:LYNCHBURG FAMILY MEDICINE AND MINOR EMERGENCY CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PA C
Authorized Official - Prefix:
Authorized Official - First Name:TODD
Authorized Official - Middle Name:DWIGHT
Authorized Official - Last Name:STEGALL
Authorized Official - Suffix:
Authorized Official - Credentials:PA C
Authorized Official - Phone:931-759-5044
Mailing Address - Street 1:12 MAGNOLIA DR
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:TN
Mailing Address - Zip Code:37352-8373
Mailing Address - Country:US
Mailing Address - Phone:931-759-5044
Mailing Address - Fax:931-759-5042
Practice Address - Street 1:12 MAGNOLIA DR
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:TN
Practice Address - Zip Code:37352-8373
Practice Address - Country:US
Practice Address - Phone:931-759-5044
Practice Address - Fax:931-759-5042
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-24
Last Update Date:2008-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0872363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4090439Medicaid
TN3373664Medicare PIN
TN3676705Medicare PIN
TN443959Medicare Oscar/Certification
TNS41220Medicare UPIN