Provider Demographics
NPI:1124111356
Name:NORTH WILLOW FAMILY MEDICINE LLC
Entity type:Organization
Organization Name:NORTH WILLOW FAMILY MEDICINE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:GREGORY
Authorized Official - Last Name:FOX
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:931-372-7788
Mailing Address - Street 1:428 N WILLOW AVE
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-2339
Mailing Address - Country:US
Mailing Address - Phone:931-372-7788
Mailing Address - Fax:031-372-7799
Practice Address - Street 1:428 N WILLOW AVE
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-2339
Practice Address - Country:US
Practice Address - Phone:931-372-7788
Practice Address - Fax:031-372-7799
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3883239Medicaid
TN4071388OtherBCBS
TN3883239Medicare ID - Type Unspecified
TNE20771Medicare UPIN