Provider Demographics
NPI:1003651563
Name:MID TN CLINIC PLLC
Entity type:Organization
Organization Name:MID TN CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:
Authorized Official - First Name:BOLA
Authorized Official - Middle Name:
Authorized Official - Last Name:GABRIEL
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:615-569-4067
Mailing Address - Street 1:3413 NOLENSVILLE PIKE
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37211-2909
Mailing Address - Country:US
Mailing Address - Phone:615-569-4067
Mailing Address - Fax:
Practice Address - Street 1:3413 NOLENSVILLE PIKE
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37211-2909
Practice Address - Country:US
Practice Address - Phone:615-569-4067
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-27
Last Update Date:2024-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent CareGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QE0002XAmbulatory Health Care FacilitiesClinic/CenterEmergency Care
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty