MEDICARE: CLINIC AT SELMER, PC

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	174400000X	Specialist	MD0000015732	TN
2	363L00000X	Nurse Practitioner	APN0000019130	TN
3	363LP2300X	Primary Care Nurse Practitioner	APN0000019129	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1780671255	OTHER	TN	NPI
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1265822027
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLINIC AT SELMER, PC

Provider Business Mailing Address
First Line	:	714 FEDERAL DR
Second Line	:
City	:	SELMER
State	:	TN
Zip	:	38375-1876
Country	:	US
Telephone Number	:	731-645-7952
Fax Number	:	731-645-8898

Provider Business Practice Location Address
First Line	:	714 FEDERAL DR
Second Line	:
City	:	SELMER
State	:	TN
Zip	:	38375-1876
Country	:	US
Telephone Number	:	731-645-7952
Fax Number	:	731-645-8898

Authorized Official
Title or Position	:	OWNER
Name	:	DR. MOHAMMED SAID BAKEER
Credential	:	M.D.
Telephone Number	:	731-645-7952

Provider Enumeration Date	:	02/02/2015
Last Update Date	:	08/12/2015

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