Basic Information
| Provider Information | |||||||||
| NPI: | 1023180478 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WEST CLINIC PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 N HUMPHREYS BLVD | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381202146 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9016830055 | ||||||||
| FaxNumber: | 9016852969 | ||||||||
| Practice Location | |||||||||
| Address1: | 1500 W POPLAR AVE | ||||||||
| Address2: | SUITE 304 | ||||||||
| City: | COLLIERVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 380170601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9018501456 | ||||||||
| FaxNumber: | 9018505830 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2006 | ||||||||
| LastUpdateDate: | 10/20/2011 | ||||||||
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| AuthorizedOfficialLastName: | DAVIS | ||||||||
| AuthorizedOfficialFirstName: | RONALD | ||||||||
| AuthorizedOfficialMiddleName: | O | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9016830055 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 0106442 | 01 | TN | BCBS TN | OTHER | 132175002 | 05 | AR | MEDICAID | 8P003 | 01 | AR | BCBS AR | OTHER | 3704066 | 05 | TN | MEDICAID | 09013755 | 05 | MS | MEDICAID | 500557509 | 05 | MO | MEDICAID |