Healthcare Provider Details

I. General information

NPI: 1629108691
Provider Name (Legal Business Name): PHYSICIAN FIRST PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 10/03/2024
Certification Date: 10/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2725 KEITH ST NW
CLEVELAND TN
37312
US

IV. Provider business mailing address

2725 KEITH ST NW
CLEVELAND TN
37312
US

V. Phone/Fax

Practice location:
  • Phone: 423-476-3330
  • Fax: 423-476-5802
Mailing address:
  • Phone: 423-476-3330
  • Fax: 423-476-5802

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD015727
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA0000000148
License Number StateTN

VIII. Authorized Official

Name: MR. GERARD K MAZZA
Title or Position: SUPERVISING
Credential: MD
Phone: 423-476-3330