Healthcare Provider Details

I. General information

NPI: 1609881150
Provider Name (Legal Business Name): MEDINA FAMILY MEDICAL CLINIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2006
Last Update Date: 10/30/2025
Certification Date: 10/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 GRACE CV
MEDINA TN
38355-8785
US

IV. Provider business mailing address

PO BOX 100
MEDINA TN
38355-0100
US

V. Phone/Fax

Practice location:
  • Phone: 731-783-0400
  • Fax: 731-783-0402
Mailing address:
  • Phone: 731-783-0400
  • Fax: 731-783-0402

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MECHELLE T PERRY
Title or Position: OWNER
Credential: CFNP
Phone: 731-783-0400