Provider Demographics
NPI:1679583801
Name:CLEARWATER INVESTMENTS INC BYRDSTOWN MEDICAL
Entity type:Organization
Organization Name:CLEARWATER INVESTMENTS INC BYRDSTOWN MEDICAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING / SYSTEMS ADMIN
Authorized Official - Prefix:
Authorized Official - First Name:DEEDEE
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:931-864-3187
Mailing Address - Street 1:8401 HWY 111
Mailing Address - Street 2:
Mailing Address - City:BYRDSTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38549-1006
Mailing Address - Country:US
Mailing Address - Phone:931-864-3187
Mailing Address - Fax:931-864-7102
Practice Address - Street 1:8401 HWY 111
Practice Address - Street 2:
Practice Address - City:BYRDSTOWN
Practice Address - State:TN
Practice Address - Zip Code:38549-1006
Practice Address - Country:US
Practice Address - Phone:931-864-3187
Practice Address - Fax:931-864-7102
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-09
Last Update Date:2024-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3714746Medicaid
TN3714746Medicaid