Provider Demographics
NPI:1295778538
Name:CENTERPOINT MEDICAL CLINIC LLC
Entity type:Organization
Organization Name:CENTERPOINT MEDICAL CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NP/CO-OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:INA
Authorized Official - Middle Name:K
Authorized Official - Last Name:BONE
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:423-247-7030
Mailing Address - Street 1:PO BOX 4842
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37602-4842
Mailing Address - Country:US
Mailing Address - Phone:423-247-7030
Mailing Address - Fax:423-247-7033
Practice Address - Street 1:2020 BROOKSIDE DRIVE
Practice Address - Street 2:SUITE 20
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660
Practice Address - Country:US
Practice Address - Phone:423-247-7030
Practice Address - Fax:423-247-7033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-14
Last Update Date:2011-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3721007Medicaid
TN3721007Medicare PIN