Healthcare Provider Details

I. General information

NPI: 1851579064
Provider Name (Legal Business Name): MY FAMILY PHYSICIAN, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2008
Last Update Date: 12/31/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3496 N MAIN ST
CROSSVILLE TN
38555-5424
US

IV. Provider business mailing address

PO BOX 3846
CROSSVILLE TN
38557-3846
US

V. Phone/Fax

Practice location:
  • Phone: 931-248-3615
  • Fax:
Mailing address:
  • Phone: 931-248-3615
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: CONNIE LEE CATRON
Title or Position: PRESIDIENT
Credential: MD
Phone: 931-248-3615