Provider Demographics
NPI:1194953364
Name:WEST CLINIC,PC
Entity type:Organization
Organization Name:WEST CLINIC,PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:O
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-683-0055
Mailing Address - Street 1:100 N HUMPHREYS BLVD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-2146
Mailing Address - Country:US
Mailing Address - Phone:901-309-4027
Mailing Address - Fax:901-312-2664
Practice Address - Street 1:1201 BISHOP ST
Practice Address - Street 2:
Practice Address - City:UNION CITY
Practice Address - State:TN
Practice Address - Zip Code:38261-5403
Practice Address - Country:US
Practice Address - Phone:901-818-0300
Practice Address - Fax:901-818-0458
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WEST CLINIC, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-06-26
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3704068Medicaid
TN3704068Medicaid