Healthcare Provider Details

I. General information

NPI: 1184919037
Provider Name (Legal Business Name): ROCKY TOP MEDICAL CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2011
Last Update Date: 09/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1595 MAIN ST SUITE B
ALTAMONT TN
37301-3639
US

IV. Provider business mailing address

PO BOX 40
ALTAMONT TN
37301-0040
US

V. Phone/Fax

Practice location:
  • Phone: 931-692-5500
  • Fax:
Mailing address:
  • Phone: 931-692-5500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD0000025899
License Number StateTN

VIII. Authorized Official

Name: MISS LORRI MCGOWAN
Title or Position: OWNER
Credential:
Phone: 931-692-5500