MEDICARE: FAMILY MEDICAL CARE CENTER, 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	261QP2300X	Primary Care Clinic/Center		TN
2	363LF0000X	Family Nurse Practitioner

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	:	1508021890
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAMILY MEDICAL CARE CENTER, LLC

Provider Business Mailing Address
First Line	:	7331 TAZEWELL PIKE
Second Line	:
City	:	CORRYTON
State	:	TN
Zip	:	37721-3516
Country	:	US
Telephone Number	:	865-687-3622
Fax Number	:	865-687-3632

Provider Business Practice Location Address
First Line	:	7331 TAZEWELL PIKE
Second Line	:
City	:	CORRYTON
State	:	TN
Zip	:	37721-3516
Country	:	US
Telephone Number	:	865-687-3622
Fax Number	:	865-687-3632

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	JAMIE BULL
Credential	:	APRN, FNP
Telephone Number	:	865-687-3622

Provider Enumeration Date	:	07/25/2008
Last Update Date	:	03/17/2015

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