Provider Demographics
NPI:1790812956
Name:LIBERTY MEDICAL CLINIC PC
Entity Type:Organization
Organization Name:LIBERTY MEDICAL CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHIZOBA
Authorized Official - Middle Name:N
Authorized Official - Last Name:NNAJI
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, FNP-BC
Authorized Official - Phone:731-663-3530
Mailing Address - Street 1:4937 COLLEGE STREET
Mailing Address - Street 2:
Mailing Address - City:BELLS
Mailing Address - State:TN
Mailing Address - Zip Code:38006-3481
Mailing Address - Country:US
Mailing Address - Phone:731-663-3530
Mailing Address - Fax:731-663-3531
Practice Address - Street 1:4937 COLLEGE ST
Practice Address - Street 2:
Practice Address - City:BELLS
Practice Address - State:TN
Practice Address - Zip Code:38006-3483
Practice Address - Country:US
Practice Address - Phone:731-663-3530
Practice Address - Fax:731-663-3531
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2017-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000032096261QP2300X
TN44-3974261QR1300X
TNAPN0000013147363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3847625Medicaid
TN0443974Medicaid
TN0443974Medicaid
TNH05855Medicare UPIN
TN3847625Medicaid