Provider Demographics
NPI:1104877703
Name:MEDICAL SPECIALTY CLINIC P.C.
Entity type:Organization
Organization Name:MEDICAL SPECIALTY CLINIC P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SANDY
Authorized Official - Middle Name:V
Authorized Official - Last Name:MORRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:731-424-1001
Mailing Address - Street 1:27 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38301-3949
Mailing Address - Country:US
Mailing Address - Phone:731-424-1001
Mailing Address - Fax:731-424-0774
Practice Address - Street 1:27 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-3949
Practice Address - Country:US
Practice Address - Phone:731-424-1001
Practice Address - Fax:731-424-0774
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN207RP1001X, 207N00000X, 207RC0000X, 207RG0100X, 207RH0003X, 207UN0902X
TN29728207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
Not Answered207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
Not Answered207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
Not Answered207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
Not Answered207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
Not Answered207UN0902XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Imaging & TherapyGroup - Multi-Specialty
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3379521Medicaid
TN3379521Medicare ID - Type UnspecifiedMEDICARE GROUP PROVIDER