Provider Demographics
NPI:1184959207
Name:WEST TENNESSEE MEDICAL GROUP INC
Entity type:Organization
Organization Name:WEST TENNESSEE MEDICAL GROUP INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JAMA
Authorized Official - Middle Name:M
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:731-512-1510
Mailing Address - Street 1:PO BOX 3669
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38303-3669
Mailing Address - Country:US
Mailing Address - Phone:731-660-8759
Mailing Address - Fax:731-660-8739
Practice Address - Street 1:1700 WOODLAWN AVE
Practice Address - Street 2:
Practice Address - City:DYERSBURG
Practice Address - State:TN
Practice Address - Zip Code:38024-2028
Practice Address - Country:US
Practice Address - Phone:731-287-4547
Practice Address - Fax:731-287-4804
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JACKSON MADISON COUNTY GENERAL HOSPITAL DISTRICT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-10-07
Last Update Date:2011-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0547380005Medicare NSC