Provider Demographics
NPI:1962414268
Name:JERNIGAN SURGERY CLINIC PLLC
Entity type:Organization
Organization Name:JERNIGAN SURGERY CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:WRIGHT
Authorized Official - Last Name:JERNIGAN
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:731-884-0002
Mailing Address - Street 1:1205 RUSSELL ST
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:TN
Mailing Address - Zip Code:38261-5352
Mailing Address - Country:US
Mailing Address - Phone:731-884-0002
Mailing Address - Fax:731-884-1555
Practice Address - Street 1:1205 RUSSELL ST
Practice Address - Street 2:
Practice Address - City:UNION CITY
Practice Address - State:TN
Practice Address - Zip Code:38261-5352
Practice Address - Country:US
Practice Address - Phone:731-884-0002
Practice Address - Fax:731-884-1555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-13
Last Update Date:2010-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNH53489Medicare UPIN