Basic Information
| Provider Information | |||||||||
| NPI: | 1467472688 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WEST CLINIC ASTC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WEST CLINIC, PC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7714 POPLAR AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | GERMANTOWN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381383941 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9016830055 | ||||||||
| FaxNumber: | 9016852969 | ||||||||
| Practice Location | |||||||||
| Address1: | 7945 WOLF RIVER BLVD | ||||||||
| Address2: | |||||||||
| City: | GERMANTOWN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 38138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9016830055 | ||||||||
| FaxNumber: | 9016852969 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2006 | ||||||||
| LastUpdateDate: | 08/20/2018 | ||||||||
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| AuthorizedOfficialLastName: | DAVIS | ||||||||
| AuthorizedOfficialFirstName: | RON | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9016830055 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WEST CLINIC, PC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 9013755 | 05 | MS | MEDICAID | 3288607 | 05 | TN | MEDICAID | 500557509 | 05 | MO | MEDICAID | 8P003 | 01 | AR | BCBS AR | OTHER | 132175002 | 05 | AR | MEDICAID | 0106442 | 01 | TN | BCBS TN | OTHER |