Provider Demographics
NPI:1740480961
Name:CARDIOVASCULAR CLINIC OF WEST TN PC
Entity type:Organization
Organization Name:CARDIOVASCULAR CLINIC OF WEST TN PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CARDIOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ADEYINKA
Authorized Official - Middle Name:ADEBORYO
Authorized Official - Last Name:AGBETOYIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:731-256-1819
Mailing Address - Street 1:2968 NORTH HIGHLAND AVENUE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-3609
Mailing Address - Country:US
Mailing Address - Phone:731-256-1819
Mailing Address - Fax:731-664-4330
Practice Address - Street 1:2968 NORTH HIGHLAND AVENUE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-3609
Practice Address - Country:US
Practice Address - Phone:731-256-1819
Practice Address - Fax:731-664-4330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-25
Last Update Date:2010-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN36918207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1501077Medicaid
TN4160707OtherBCBS
TN4160707OtherBCBS
G76663Medicare UPIN