Provider Demographics
NPI:1790978294
Name:NEWBERN MEDICAL CLINIC, PC
Entity Type:Organization
Organization Name:NEWBERN MEDICAL CLINIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BEVERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCANN
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:731-627-0734
Mailing Address - Street 1:105 N MONROE ST
Mailing Address - Street 2:
Mailing Address - City:NEWBERN
Mailing Address - State:TN
Mailing Address - Zip Code:38059-1214
Mailing Address - Country:US
Mailing Address - Phone:731-627-0734
Mailing Address - Fax:731-627-0736
Practice Address - Street 1:105 N MONROE ST
Practice Address - Street 2:
Practice Address - City:NEWBERN
Practice Address - State:TN
Practice Address - Zip Code:38059-1214
Practice Address - Country:US
Practice Address - Phone:731-627-0734
Practice Address - Fax:731-627-0736
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-20
Last Update Date:2007-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN5297261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3727670OtherMEDICARE