MEDICARE: FAMILY CLINIC OF 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	207Q00000X	Family Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1487290110
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAMILY CLINIC OF SELMER, PC

Provider Business Mailing Address
First Line	:	832 MULBERRY AVE STE B
Second Line	:
City	:	SELMER
State	:	TN
Zip	:	38375-2334
Country	:	US
Telephone Number	:	731-434-0201
Fax Number	:	731-434-0203

Provider Business Practice Location Address
First Line	:	832 MULBERRY AVE STE B
Second Line	:
City	:	SELMER
State	:	TN
Zip	:	38375-2334
Country	:	US
Telephone Number	:	731-434-0201
Fax Number	:	731-434-0203

Authorized Official
Title or Position	:	OWNER
Name	:	DR. MARY JANE DICKEY
Credential	:	MD
Telephone Number	:	731-607-7484

Provider Enumeration Date	:	11/18/2019
Last Update Date	:	01/27/2020

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