=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073606778
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EAST WOOD CLINIC PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/02/2006
-----------------------------------------------------
Last Update Date | 10/08/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1323 EAST WOOD STREET
-----------------------------------------------------
City | PARIS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38242-4421
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 731-642-2011
-----------------------------------------------------
Fax | 731-644-2758
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1323 EAST WOOD STREET
-----------------------------------------------------
City | PARIS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38242-4421
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 731-642-2011
-----------------------------------------------------
Fax | 731-644-2758
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | JOSHUA DAVID ROBERTS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 731-641-8728
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------