MEDICARE: TAZEWELL MEDICAL CLINIC, INC.

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	261Q00000X	Clinic/Center	PA476	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4043299	OTHER	TN	BCBS-T GROUP NUMBER

General Provider Information

NPI Number	:	1417001645
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TAZEWELL MEDICAL CLINIC, INC.

Provider Business Mailing Address
First Line	:	1442 N BROAD ST
Second Line	:	SUITE 7
City	:	TAZEWELL
State	:	TN
Zip	:	37879-4361
Country	:	US
Telephone Number	:	423-626-6145
Fax Number	:	423-526-2804

Provider Business Practice Location Address
First Line	:	1442 N BROAD ST
Second Line	:	SUITE 7
City	:	TAZEWELL
State	:	TN
Zip	:	37879-4361
Country	:	US
Telephone Number	:	423-626-6145
Fax Number	:	423-526-2804

Authorized Official
Title or Position	:	PRESIDENT
Name	:	RONDAL KEITH BROCK
Credential	:	P.A.C.
Telephone Number	:	423-626-6145

Provider Enumeration Date	:	01/23/2007
Last Update Date	:	08/22/2020

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