Healthcare Provider Details

I. General information

NPI: 1073606778
Provider Name (Legal Business Name): EAST WOOD CLINIC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 10/08/2021
Certification Date: 10/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1323 EAST WOOD STREET
PARIS TN
38242-4421
US

IV. Provider business mailing address

1323 EAST WOOD STREET
PARIS TN
38242-4421
US

V. Phone/Fax

Practice location:
  • Phone: 731-642-2011
  • Fax: 731-644-2758
Mailing address:
  • Phone: 731-642-2011
  • Fax: 731-644-2758

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 Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JOSHUA DAVID ROBERTS
Title or Position: ADMINISTRATOR
Credential:
Phone: 731-641-8728