MEDICARE: LYNCHBURG MEDICAL CLINIC, 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	47136	TN

General Provider Information

NPI Number	:	1982949434
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LYNCHBURG MEDICAL CLINIC, LLC

Provider Business Mailing Address
First Line	:	100 WILLIAM NORTHERN BLVD
Second Line	:
City	:	TULLAHOMA
State	:	TN
Zip	:	37388-4754
Country	:	US
Telephone Number	:	931-454-0489
Fax Number	:	931-454-1227

Provider Business Practice Location Address
First Line	:	40 LYNCHBURG HWY
Second Line	:
City	:	LYNCHBURG
State	:	TN
Zip	:	37352-7449
Country	:	US
Telephone Number	:	931-759-4197
Fax Number	:	931-759-6673

Authorized Official
Title or Position	:	MEMBER
Name	:	BRETT L FERRELL
Credential	:	MD
Telephone Number	:	931-454-0489

Provider Enumeration Date	:	12/10/2012
Last Update Date	:	03/27/2013

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