Healthcare Provider Details

I. General information

NPI: 1235594748
Provider Name (Legal Business Name): PRIMARY CARE SPECIALISTS OF WEST TENNESSEE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2015
Last Update Date: 12/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1385 S HIGHLAND AVE STE, B-1
JACKSON TN
38301-7525
US

IV. Provider business mailing address

1385 S HIGHLAND AVE STE, B-1
JACKSON TN
38301-7525
US

V. Phone/Fax

Practice location:
  • Phone: 731-427-0470
  • Fax: 731-427-0995
Mailing address:
  • Phone: 731-427-0470
  • Fax: 731-427-0995

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number041832
License Number StateTN

VIII. Authorized Official

Name: MIKE COLEMAN
Title or Position: PRESIDENT
Credential:
Phone: 731-427-0470