Healthcare Provider Details

I. General information

NPI: 1326768870
Provider Name (Legal Business Name): MADISONVILLE PRIMARY CARE GROUP PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/02/2022
Last Update Date: 11/04/2024
Certification Date: 11/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 W WASHINGTON AVE
ATHENS TN
37303-3468
US

IV. Provider business mailing address

PO BOX 808
KINGSTON TN
37763-0808
US

V. Phone/Fax

Practice location:
  • Phone: 423-745-6610
  • Fax: 423-745-6360
Mailing address:
  • Phone: 865-224-7172
  • Fax: 865-224-7171

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: GREGORY BRIAN CAIN
Title or Position: OWNER
Credential: PA-C
Phone: 423-442-2121