Healthcare Provider Details

I. General information

NPI: 1154318954
Provider Name (Legal Business Name): MEMORIAL DRIVE FAMILY PRACTICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2005
Last Update Date: 01/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

306 LANDRUM PL
CLARKSVILLE TN
37043-4648
US

IV. Provider business mailing address

PO BOX 3857
CLARKSVILLE TN
37043-0857
US

V. Phone/Fax

Practice location:
  • Phone: 931-648-1920
  • Fax: 931-503-0346
Mailing address:
  • Phone: 931-648-1920
  • Fax: 931-503-0346

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberD0769
License Number StateTN

VIII. Authorized Official

Name: STEPHAN SCHOTT
Title or Position: PHYSICIAN
Credential: D.O.
Phone: 931-648-1920