Provider Demographics
NPI:1972645802
Name:MADISON FAM WALK IN CLINIC LIMITED
Entity Type:Organization
Organization Name:MADISON FAM WALK IN CLINIC LIMITED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:FULTON
Authorized Official - Last Name:WEEKS
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:731-423-8600
Mailing Address - Street 1:1660 S HIGHLAND AVE STE J
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38301-7797
Mailing Address - Country:US
Mailing Address - Phone:731-423-8600
Mailing Address - Fax:731-423-8636
Practice Address - Street 1:1660 S HIGHLAND AVE STE J
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-7797
Practice Address - Country:US
Practice Address - Phone:731-423-8600
Practice Address - Fax:731-423-8636
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2010-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3724655Medicaid
TN3724655Medicaid