Provider Demographics
NPI:1770781544
Name:FAMILY PRACTICE OF COVINGTON, INC
Entity type:Organization
Organization Name:FAMILY PRACTICE OF COVINGTON, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE ASSISTANT
Authorized Official - Prefix:MS
Authorized Official - First Name:SOPHIA
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-475-4752
Mailing Address - Street 1:P.O. BOX 507
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:TN
Mailing Address - Zip Code:38019-0507
Mailing Address - Country:US
Mailing Address - Phone:901-475-4752
Mailing Address - Fax:901-475-1554
Practice Address - Street 1:4235 HIGHWAY 51 SOUTH
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:TN
Practice Address - Zip Code:38011-6921
Practice Address - Country:US
Practice Address - Phone:901-475-4752
Practice Address - Fax:901-475-1554
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-03
Last Update Date:2009-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD11374207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4063363OtherBCBSTN
TN3718265Medicaid
TN4229920OtherBLUE CROSS BLUE SHIELD OF TN
TN268267OtherUNISON ADVANTAGE
TN27017OtherTLC
TN27017OtherTLC
A98179Medicare UPIN
TN3A98179Medicare UPIN
30179512Medicare PIN
TN4229920OtherBLUE CROSS BLUE SHIELD OF TN
TN30179511Medicare PIN