Basic Information
| Provider Information | |||||||||
| NPI: | 1194998856 | ||||||||
| 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: | 2996 KATE BOND RD | ||||||||
| Address2: | SUITE 303 | ||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381334030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9016830055 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2008 | ||||||||
| LastUpdateDate: | 10/20/2011 | ||||||||
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| AuthorizedOfficialLastName: | DAVIS | ||||||||
| AuthorizedOfficialFirstName: | RON | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9016830055 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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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 | 132175002 | 05 | AR | MEDICAID | 8P003 | 01 | AR | BCBS AR | OTHER | 09013755 | 05 | MS | MEDICAID | 500557509 | 05 | MO | MEDICAID | 0106442 | 01 | TN | BCBS TN | OTHER | 3704066 | 05 | TN | MEDICAID |