Provider Demographics
NPI:1972524239
Name:JEFFERSON FAMILY PHYSICIANS P C
Entity Type:Organization
Organization Name:JEFFERSON FAMILY PHYSICIANS P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AN OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DEWAYNE
Authorized Official - Middle Name:P
Authorized Official - Last Name:DARBY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:865-475-6161
Mailing Address - Street 1:1810 BISHOP AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37760-1997
Mailing Address - Country:US
Mailing Address - Phone:865-475-6161
Mailing Address - Fax:865-475-9857
Practice Address - Street 1:1810 BISHOP AVE
Practice Address - Street 2:SUITE A
Practice Address - City:JEFFERSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37760-1997
Practice Address - Country:US
Practice Address - Phone:865-475-6161
Practice Address - Fax:865-475-9857
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3712179Medicaid
TN3712170Medicaid
TN3712179Medicaid
TN3712179Medicare ID - Type Unspecified