Provider Demographics
NPI:1154353092
Name:MEMORIAL CLINIC P.C.
Entity type:Organization
Organization Name:MEMORIAL CLINIC P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BONNIE
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:JUDD
Authorized Official - Suffix:
Authorized Official - Credentials:APN
Authorized Official - Phone:931-296-5833
Mailing Address - Street 1:203 E COMMERCE ST
Mailing Address - Street 2:
Mailing Address - City:WAVERLY
Mailing Address - State:TN
Mailing Address - Zip Code:37185-1629
Mailing Address - Country:US
Mailing Address - Phone:931-296-5833
Mailing Address - Fax:931-296-7388
Practice Address - Street 1:203 E COMMERCE ST
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:TN
Practice Address - Zip Code:37185-1629
Practice Address - Country:US
Practice Address - Phone:931-296-5833
Practice Address - Fax:931-296-7388
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2015-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN36404232Medicaid
TN36404232Medicare PIN