Provider Demographics
NPI:1801084926
Name:EVANSTON CLINIC CORP
Entity type:Organization
Organization Name:EVANSTON CLINIC CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PROVIDER ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:T
Authorized Official - Last Name:BREWER
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:615-465-7626
Mailing Address - Street 1:7100 COMMERCE WAY
Mailing Address - Street 2:SUITE 180
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-2829
Mailing Address - Country:US
Mailing Address - Phone:615-465-7626
Mailing Address - Fax:
Practice Address - Street 1:107 N MAIN ST
Practice Address - Street 2:
Practice Address - City:LYMAN
Practice Address - State:WY
Practice Address - Zip Code:82937
Practice Address - Country:US
Practice Address - Phone:307-787-3313
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EVANSTON CLINIC CORP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-10-15
Last Update Date:2007-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY308482Medicare PIN