=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457350951
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CLEVELAND MEDICAL CLINIC INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/18/2005
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2305 CHAMBLISS AVE NW
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37311-3847
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-728-1650
-----------------------------------------------------
Fax | 423-728-1655
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4000 MERIDIAN BLVD
-----------------------------------------------------
City | FRANKLIN
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37067-6325
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-287-7705
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | DEBBIE BREWER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 877-892-9813
-----------------------------------------------------
=====================================================
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 | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 2084N0400X
-----------------------------------------------------
Taxonomy Name | Neurology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 207RN0300X
-----------------------------------------------------
Taxonomy Name | Nephrology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #7
-----------------------------------------------------
Taxonomy Code | 207XS0117X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery of the Spine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------