Provider Demographics
NPI:1184102881
Name:A PATTERN MEDICAL CLINIC
Entity type:Organization
Organization Name:A PATTERN MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:ANNEX
Authorized Official - Middle Name:
Authorized Official - Last Name:LUBERISSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:660-229-0858
Mailing Address - Street 1:5545 LITTLE DEBBIE PKWY
Mailing Address - Street 2:
Mailing Address - City:OOLTEWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37363-4357
Mailing Address - Country:US
Mailing Address - Phone:660-229-0858
Mailing Address - Fax:
Practice Address - Street 1:5545 LITTLE DEBBIE PKWY
Practice Address - Street 2:
Practice Address - City:OOLTEWAH
Practice Address - State:TN
Practice Address - Zip Code:37363-4357
Practice Address - Country:US
Practice Address - Phone:423-455-2711
Practice Address - Fax:423-465-4589
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-03
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL207Q00000X
261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ057324Medicaid