Provider Demographics
NPI:1457401416
Name:WEST CLINIC PC
Entity Type:Organization
Organization Name:WEST CLINIC PC
Other - Org Name:MEMPHIS HEART CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:O
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-683-0055
Mailing Address - Street 1:100 N HUMPHREYS BLVD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-2146
Mailing Address - Country:US
Mailing Address - Phone:901-683-0055
Mailing Address - Fax:901-322-9097
Practice Address - Street 1:6025 WALNUT GROVE RD
Practice Address - Street 2:STE. 111
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-2102
Practice Address - Country:US
Practice Address - Phone:901-818-0300
Practice Address - Fax:901-818-0458
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-11
Last Update Date:2011-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR8P003OtherBCBS
MS09015177Medicaid
TNCN1272OtherRAIL ROAD MEDICARE
TN7100204OtherAETNA
TN3704068Medicaid
MSCH5373OtherRAIL ROAD MEDICARE
=========OtherCHAMPUS
MSCH5373OtherRAIL ROAD MEDICARE
TN7100204OtherAETNA