Healthcare Provider Details

I. General information

NPI: 1679612949
Provider Name (Legal Business Name): MEDWEST FAMILY PRACTICE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 03/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 FREY ST SUITE 100
ASHLAND CITY TN
37015-1792
US

IV. Provider business mailing address

PO BOX 24010
NASHVILLE TN
37202-4010
US

V. Phone/Fax

Practice location:
  • Phone: 615-792-2292
  • Fax: 615-792-2207
Mailing address:
  • Phone: 615-792-2292
  • Fax: 615-376-0199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: LANCE GARDINER
Title or Position: ADMINISTRATOR
Credential:
Phone: 615-792-2292