=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336199041
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMILY HEALTH GROUP INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/11/2006
-----------------------------------------------------
Last Update Date | 06/10/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 107 J V MANGUAT DR
-----------------------------------------------------
City | WAYNESBORO
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38485-2440
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 931-722-2800
-----------------------------------------------------
Fax | 931-722-9627
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 854 W JAMES CAMPBELL BLVD SUITE 303
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38401-4659
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 931-540-4255
-----------------------------------------------------
Fax | 931-490-4654
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. HAROLD E PRESTON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 931-540-4255
-----------------------------------------------------
=====================================================
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 | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------