Provider Demographics
NPI:1760509673
Name:FAMILY PHYSICIANS OF ESTILL SPRINGS, P.C.
Entity type:Organization
Organization Name:FAMILY PHYSICIANS OF ESTILL SPRINGS, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:BOYANTON
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:931-649-5139
Mailing Address - Street 1:300 S. MAIN ST.
Mailing Address - Street 2:P.O. BOX 700
Mailing Address - City:ESTILL SPRINGS
Mailing Address - State:TN
Mailing Address - Zip Code:37330
Mailing Address - Country:US
Mailing Address - Phone:931-649-5139
Mailing Address - Fax:931-649-2766
Practice Address - Street 1:300 S. MAIN ST.
Practice Address - Street 2:
Practice Address - City:ESTILL SPRINGS
Practice Address - State:TN
Practice Address - Zip Code:37330
Practice Address - Country:US
Practice Address - Phone:931-649-5139
Practice Address - Fax:931-649-2766
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN17539173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3376322Medicare ID - Type Unspecified