Provider Demographics
NPI:1972834414
Name:SOMERVILLE MEDICAL CLINIC,INC
Entity Type:Organization
Organization Name:SOMERVILLE MEDICAL CLINIC,INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RAYNOR
Authorized Official - Middle Name:
Authorized Official - Last Name:SHOAF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-465-5466
Mailing Address - Street 1:PO BOX 640
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38068-0640
Mailing Address - Country:US
Mailing Address - Phone:901-465-5466
Mailing Address - Fax:901-465-9048
Practice Address - Street 1:213 LAKEVIEW RD
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:TN
Practice Address - Zip Code:38068-9744
Practice Address - Country:US
Practice Address - Phone:901-465-5466
Practice Address - Fax:901-465-9048
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-22
Last Update Date:2011-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1437245792OtherJAMEY COLSTON FNP NPI
TN1972834414OtherSOMERVILLE MEDICAL CLINIC,INC NPI
TN4108029OtherBLUE CROSS GROUP
TN1518107Medicaid
TN1487748745OtherDR. DAVID SEATON NPI
TN1629018981OtherASHLEY CRAWFORD FNP NPI