Provider Demographics
NPI:1104839703
Name:CROCKETT MEDICAL CLINIC INC
Entity type:Organization
Organization Name:CROCKETT MEDICAL CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:JERMAN
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:731-696-4670
Mailing Address - Street 1:58 S. BELLS ST
Mailing Address - Street 2:
Mailing Address - City:ALAMO
Mailing Address - State:TN
Mailing Address - Zip Code:38001
Mailing Address - Country:US
Mailing Address - Phone:731-696-5401
Mailing Address - Fax:731-696-5404
Practice Address - Street 1:58 S. BELLS ST
Practice Address - Street 2:
Practice Address - City:ALAMO
Practice Address - State:TN
Practice Address - Zip Code:38001
Practice Address - Country:US
Practice Address - Phone:731-696-5401
Practice Address - Fax:731-696-5404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-14
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3717707Medicaid
TN3717707OtherPTAN