Healthcare Provider Details

I. General information

NPI: 1306809199
Provider Name (Legal Business Name): MCMINNVILLE ORTHOPAEDIC CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2006
Last Update Date: 05/26/2021
Certification Date: 05/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 OLD MAIN ST
HARTFORD KY
42347-1619
US

IV. Provider business mailing address

207 OAK PARK
MC MINNVILLE TN
37110-1336
US

V. Phone/Fax

Practice location:
  • Phone: 270-730-5344
  • Fax:
Mailing address:
  • Phone: 931-473-9624
  • Fax: 931-473-7718

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DOUGLAS BRANDT HAYNES
Title or Position: PARTNER
Credential: M.D.
Phone: 931-473-9624