Provider Demographics
NPI:1679929285
Name:PEDIATRIC ASSOCIATES OF WEST TENNESSEE PLLC
Entity Type:Organization
Organization Name:PEDIATRIC ASSOCIATES OF WEST TENNESSEE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:ELLERBROOK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:731-285-4111
Mailing Address - Street 1:1501 BRAYTON AVE
Mailing Address - Street 2:
Mailing Address - City:DYERSBURG
Mailing Address - State:TN
Mailing Address - Zip Code:38024-3158
Mailing Address - Country:US
Mailing Address - Phone:731-285-4111
Mailing Address - Fax:
Practice Address - Street 1:1501 BRAYTON AVE
Practice Address - Street 2:
Practice Address - City:DYERSBURG
Practice Address - State:TN
Practice Address - Zip Code:38024-3158
Practice Address - Country:US
Practice Address - Phone:731-285-4111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-12
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN261QR1300X
TN0000014756363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty