Provider Demographics
NPI:1487290110
Name:FAMILY CLINIC OF SELMER, PC
Entity type:Organization
Organization Name:FAMILY CLINIC OF SELMER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:DICKEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:731-607-7484
Mailing Address - Street 1:832 MULBERRY AVE STE B
Mailing Address - Street 2:
Mailing Address - City:SELMER
Mailing Address - State:TN
Mailing Address - Zip Code:38375-2334
Mailing Address - Country:US
Mailing Address - Phone:731-434-0201
Mailing Address - Fax:731-434-0203
Practice Address - Street 1:832 MULBERRY AVE STE B
Practice Address - Street 2:
Practice Address - City:SELMER
Practice Address - State:TN
Practice Address - Zip Code:38375-2334
Practice Address - Country:US
Practice Address - Phone:731-434-0201
Practice Address - Fax:731-434-0203
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-18
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ053134Medicaid