Basic Information
Provider Information | |||||||||
NPI: | 1770900268 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | THE WEST CLINIC, PLLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | WEST CLINIC, PLLC | ||||||||
OtherOrganizationType: | 4 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 7714 POPLAR AVE STE 200 | ||||||||
Address2: |   | ||||||||
City: | GERMANTOWN | ||||||||
State: | TN | ||||||||
PostalCode: | 381383941 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9016830055 | ||||||||
FaxNumber: | 9019226722 | ||||||||
Practice Location | |||||||||
Address1: | 1290 KELLEY DR | ||||||||
Address2: |   | ||||||||
City: | PARIS | ||||||||
State: | TN | ||||||||
PostalCode: | 382424745 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9016830055 | ||||||||
FaxNumber: | 9013222955 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/24/2014 | ||||||||
LastUpdateDate: | 12/14/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GRAVES | ||||||||
AuthorizedOfficialFirstName: | JOHN | ||||||||
AuthorizedOfficialMiddleName: | M | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 9016830055 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/14/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
ID | Type | State | Issuer | Description | 3704066 | 05 | TN |   | MEDICAID |