Healthcare Provider Details

I. General information

NPI: 1417513177
Provider Name (Legal Business Name): SOUTHERN ALLERGY AND MEDICAL CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2019
Last Update Date: 05/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 MAIN ST
NEW TAZEWELL TN
37825-6635
US

IV. Provider business mailing address

PO BOX 69
NEW TAZEWELL TN
37824-0069
US

V. Phone/Fax

Practice location:
  • Phone: 423-259-5704
  • Fax: 423-259-5706
Mailing address:
  • Phone: 423-259-5704
  • Fax: 423-259-5706

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name: SASHA LASHEA' BUSSELL
Title or Position: OWNER
Credential:
Phone: 423-489-5841