Provider Demographics
NPI:1972141620
Name:PRIMARY CARE - BEMIS, LLC
Entity Type:Organization
Organization Name:PRIMARY CARE - BEMIS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CASEY
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:MARCOM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:731-300-7755
Mailing Address - Street 1:1385 S HIGHLAND AVE STE B4
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38301-7547
Mailing Address - Country:US
Mailing Address - Phone:731-300-7755
Mailing Address - Fax:731-300-0773
Practice Address - Street 1:1385 S HIGHLAND AVE STE B4
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-7547
Practice Address - Country:US
Practice Address - Phone:731-300-7755
Practice Address - Fax:731-300-0773
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-12
Last Update Date:2019-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN5441759Medicaid