Healthcare Provider Details

I. General information

NPI: 1659364669
Provider Name (Legal Business Name): LYNCHBURG FAMILY MEDICINE AND MINOR EMERGENCY CENTER PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2005
Last Update Date: 09/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 MAGNOLIA DR
LYNCHBURG TN
37352-8373
US

IV. Provider business mailing address

12 MAGNOLIA DR
LYNCHBURG TN
37352-8373
US

V. Phone/Fax

Practice location:
  • Phone: 931-759-5044
  • Fax: 931-759-5042
Mailing address:
  • Phone: 931-759-5044
  • Fax: 931-759-5042

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0872
License Number StateTN

VIII. Authorized Official

Name: TODD DWIGHT STEGALL
Title or Position: PA C
Credential: PA C
Phone: 931-759-5044