=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801602271
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE WEST CLINIC, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/10/2024
-----------------------------------------------------
Last Update Date | 12/10/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6055 PRIMACY PKWY STE 100
-----------------------------------------------------
City | MEMPHIS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38119-5514
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-440-4129
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7714 POPLAR AVE STE 200
-----------------------------------------------------
City | GERMANTOWN
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38138-3941
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-683-0055
-----------------------------------------------------
Fax | 901-922-6722
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | JOHN MITCHELL GRAVES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 901-683-0055
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RH0003X
-----------------------------------------------------
Taxonomy Name | Hematology & Oncology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------