Healthcare Provider Details

I. General information

NPI: 1700197183
Provider Name (Legal Business Name): PATIENT CENTERED PHYSICIAN'S CARE, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2010
Last Update Date: 08/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 SECURITY DR
JACKSON TN
38305-3754
US

IV. Provider business mailing address

25 SECURITY DR
JACKSON TN
38305-3754
US

V. Phone/Fax

Practice location:
  • Phone: 731-215-2888
  • Fax: 731-215-2880
Mailing address:
  • Phone: 731-215-2888
  • Fax: 731-215-2880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number31314
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number31314
License Number StateTN

VIII. Authorized Official

Name: KIMBERLY A HOWERTON
Title or Position: MD
Credential: MD
Phone: 731-215-2888