Healthcare Provider Details

I. General information

NPI: 1861780496
Provider Name (Legal Business Name): MADISONVILLE PRIMARY CARE GROUP PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2011
Last Update Date: 11/05/2024
Certification Date: 11/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3959 HIGHWAY 411
MADISONVILLE TN
37354-4417
US

IV. Provider business mailing address

PO BOX 808
KINGSTON TN
37763-0808
US

V. Phone/Fax

Practice location:
  • Phone: 423-442-2121
  • Fax: 423-545-9556
Mailing address:
  • Phone: 865-224-7172
  • Fax: 865-224-7171

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. GREGORY BRIAN CAIN
Title or Position: OWNER
Credential: PA
Phone: 423-442-2121