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General NPI Number Information
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NPI Number | 1275168817
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Entity Type | Organization
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Legal Business Name | SOUTH MEDICAL CLINIC LLC
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Dates
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Enumeration Date | 03/04/2020
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Last Update Date | 03/04/2020
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Provider Practice Location Address
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Address Line | 118 2ND AVE SOUTH
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City | LEWISBURG
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State | TN
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Zip | 37091
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Country | US
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Telephone | 931-422-5029
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Fax | 931-422-5229
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Provider Business Mailing Address
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Address Line | 118 2ND AVE SOUTH
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City | LEWISBURG
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State | TN
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Zip | 37091
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Country | US
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Telephone | 931-422-5029
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Fax | 931-422-5229
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | EDITH ANN WILES
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Credential |
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Telephone | 931-422-5029
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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