MEDICARE: FAMILY WELLNESS GROUP OF MIDDLE TENNESSEE LLC

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

General Provider Information

NPI Number	:	1639324056
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAMILY WELLNESS GROUP OF MIDDLE TENNESSEE LLC

Provider Business Mailing Address
First Line	:	PO BOX 1558
Second Line	:	SUMNER REGIONAL HEALTH SYSTEMS INC
City	:	GALLATIN
State	:	TN
Zip	:	37066-4747
Country	:	US
Telephone Number	:	615-822-2400
Fax Number	:	615-822-9641

Provider Business Practice Location Address
First Line	:	107 GLEN OAK BLVD STE 201
Second Line	:	GLEN OAKS CENTER
City	:	HENDERSONVILLE
State	:	TN
Zip	:	37075-3000
Country	:	US
Telephone Number	:	615-822-2400
Fax Number	:	615-822-9641

Authorized Official
Title or Position	:	VICE PRESIDENT & FAMILY WELLNESS GR
Name	:	MR. DAVID L YOUNG
Credential	:
Telephone Number	:	615-328-6600

Provider Enumeration Date	:	11/26/2008
Last Update Date	:	03/09/2010

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