MEDICARE: WHITE BLUFF FAMILY HEALTH CARE CENTER INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	93835	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1407952799
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WHITE BLUFF FAMILY HEALTH CARE CENTER INC

Provider Business Mailing Address
First Line	:	PO BOX 624
Second Line	:
City	:	GOODLETTSVILLE
State	:	TN
Zip	:	37070-0624
Country	:	US
Telephone Number	:	615-797-3646
Fax Number	:	615-797-4055

Provider Business Practice Location Address
First Line	:	2004 HIGHWAY 47 NORTH
Second Line	:
City	:	WHITE BLUFF
State	:	TN
Zip	:	37187
Country	:	US
Telephone Number	:	615-797-3646
Fax Number	:	615-797-4055

Authorized Official
Title or Position	:	OWNER
Name	:	MR. EDWIN SIMON
Credential	:	FNP
Telephone Number	:	615-797-3646

Provider Enumeration Date	:	09/15/2006
Last Update Date	:	02/14/2008

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