MEDICARE: COLLEGE PARK WALK-IN CLINIC, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1174602338
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COLLEGE PARK WALK-IN CLINIC, LLC

Provider Business Mailing Address
First Line	:	PO BOX 1237
Second Line	:
City	:	MORRISTOWN
State	:	TN
Zip	:	37816-1237
Country	:	US
Telephone Number	:	423-318-6093
Fax Number	:	423-318-6297

Provider Business Practice Location Address
First Line	:	2104 E ANDREW JOHNSON HWY
Second Line	:
City	:	MORRISTOWN
State	:	TN
Zip	:	37814-5412
Country	:	US
Telephone Number	:	423-318-6093
Fax Number	:	423-318-6297

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	BETH D YOUNG
Credential	:
Telephone Number	:	423-318-6093

Provider Enumeration Date	:	11/06/2006
Last Update Date	:	09/27/2007

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