Healthcare Provider Details

I. General information

NPI: 1205120284
Provider Name (Legal Business Name): FAMILY MEDICAL CLINIC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2011
Last Update Date: 06/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

144 MEDICAL CENTER DR STE C
COPPERHILL TN
37317-5006
US

IV. Provider business mailing address

PO BOX 726
DUCKTOWN TN
37326-0726
US

V. Phone/Fax

Practice location:
  • Phone: 423-548-1500
  • Fax: 423-548-1604
Mailing address:
  • Phone: 423-761-0085
  • Fax: 423-496-4840

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 Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License NumberMD21234
License Number StateTN

VIII. Authorized Official

Name: STEVEN WILFRED GARST
Title or Position: SOLE MBR
Credential: MD
Phone: 423-761-0085