Healthcare Provider Details

I. General information

NPI: 1114079316
Provider Name (Legal Business Name): WILKENS MEDICAL GROUP INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2007
Last Update Date: 11/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 HOSPITAL LN
JELLICO TN
37762-4404
US

IV. Provider business mailing address

PO BOX 28
JELLICO TN
37762-0028
US

V. Phone/Fax

Practice location:
  • Phone: 423-784-7269
  • Fax: 423-784-3708
Mailing address:
  • Phone: 423-784-7269
  • Fax: 423-784-3708

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DEBRA J SHARP
Title or Position: ADMINISTRATION
Credential:
Phone: 423-784-3667