Provider Demographics
NPI:1831312461
Name:WEST TENNESSEE BONE AND JOINT CLINIC PC
Entity Type:Organization
Organization Name:WEST TENNESSEE BONE AND JOINT CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:W
Authorized Official - Last Name:KLUTTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:731-661-9825
Mailing Address - Street 1:24 PHYSICIANS DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-2070
Mailing Address - Country:US
Mailing Address - Phone:731-661-9825
Mailing Address - Fax:731-668-6757
Practice Address - Street 1:24 PHYSICIANS DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-2085
Practice Address - Country:US
Practice Address - Phone:731-410-2308
Practice Address - Fax:731-668-6757
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD08163174400000X
TN0369490001332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3375781Medicaid
TN3153344Medicare ID - Type Unspecified
TN3171724Medicare ID - Type Unspecified
TN3826433Medicare ID - Type Unspecified
TN3375781Medicaid
TN38958521Medicare PIN
TN3893139Medicare ID - Type Unspecified
TN0369490001Medicare NSC
TN3826057Medicare ID - Type Unspecified
TN3882874Medicare ID - Type Unspecified
TN3025552Medicare ID - Type Unspecified