=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659364669
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LYNCHBURG FAMILY MEDICINE AND MINOR EMERGENCY CENTER PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/24/2005
-----------------------------------------------------
Last Update Date | 09/22/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12 MAGNOLIA DR
-----------------------------------------------------
City | LYNCHBURG
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37352-8373
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 931-759-5044
-----------------------------------------------------
Fax | 931-759-5042
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12 MAGNOLIA DR
-----------------------------------------------------
City | LYNCHBURG
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37352-8373
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 931-759-5044
-----------------------------------------------------
Fax | 931-759-5042
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PA C
-----------------------------------------------------
Name | TODD DWIGHT STEGALL
-----------------------------------------------------
Credential | PA C
-----------------------------------------------------
Telephone | 931-759-5044
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 0872
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------