Healthcare Provider Details

I. General information

NPI: 1043240716
Provider Name (Legal Business Name): WEST TENNESSEE ORTHOPEDICS AND SPORTS MEDICINE,P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 01/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

569 SKYLINE DR SUITE 100
JACKSON TN
38301-3911
US

IV. Provider business mailing address

569 SKYLINE DR SUITE 100
JACKSON TN
38301-3911
US

V. Phone/Fax

Practice location:
  • Phone: 731-427-7888
  • Fax: 731-265-4152
Mailing address:
  • Phone: 731-427-7888
  • Fax: 731-265-4152

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number26655
License Number StateTN

VIII. Authorized Official

Name: MRS. KAY JORDAN
Title or Position: ADMINISTRATOR
Credential:
Phone: 731-427-7888