Provider Demographics
NPI:1962796888
Name:WAVERLY PEDIATRIC AND ADULT CARE
Entity type:Organization
Organization Name:WAVERLY PEDIATRIC AND ADULT CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:ANGELA
Authorized Official - Last Name:SKELTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:931-296-7000
Mailing Address - Street 1:1034 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WAVERLY
Mailing Address - State:TN
Mailing Address - Zip Code:37185-1447
Mailing Address - Country:US
Mailing Address - Phone:931-296-7000
Mailing Address - Fax:931-296-7231
Practice Address - Street 1:1034 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:TN
Practice Address - Zip Code:37185-1447
Practice Address - Country:US
Practice Address - Phone:931-296-7000
Practice Address - Fax:931-296-7231
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-08
Last Update Date:2011-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD87192080A0000X
TNAPN0000015777364SF0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Multi-Specialty
No364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily HealthGroup - Multi-Specialty