Basic Information
| Provider Information | |||||||||
| NPI: | 1932780459 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THE WEST CLINIC, PLLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WEST CLINIC, PC | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7714 POPLAR AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | GERMANTOWN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381383941 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9016830055 | ||||||||
| FaxNumber: | 9019226722 | ||||||||
| Practice Location | |||||||||
| Address1: | 440 WILKINSON DR | ||||||||
| Address2: | |||||||||
| City: | DYERSBURG | ||||||||
| State: | TN | ||||||||
| PostalCode: | 380242085 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7312852211 | ||||||||
| FaxNumber: | 7312858222 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2021 | ||||||||
| LastUpdateDate: | 12/14/2021 | ||||||||
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| AuthorizedOfficialLastName: | GRAVES | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | MITCHELL | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9016830055 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 12/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 2085R0001X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | 3704066 | 05 | TN | MEDICAID |