Grace Family Practice Clinic, P.C.
Organization Active NPI Family Medicine Physician · Dyersburg, TN
NPI 1083124671 · NPPES record last updated Oct 9, 2017
Key facts
- NPI
- 1083124671
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Family Medicine Physician 207Q00000X
- License
- MD35727 (TN)
- Legal business name
- GRACE FAMILY PRACTICE CLINIC, P.C.
- Practice address
- 1716 Parr Ave Ste D
Dyersburg, TN 38024-2074 - Phone
- (731) 288-0911
- Fax
- (731) 288-0065
- NPI assigned
- Oct 9, 2017
- Organization subpart
- No
Authorized official
- Name
- Monique Casey-Bolden, M.D.
- Title
- President
- Phone
- (731) 288-0911
Practitioners 3
-
Rhiannon Michelle Andresen, FNP-C
-
Sandra Dennis, FNP
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in TN
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20171207001940 | TN | Part B Supplier - Clinic/Group Practice | 9537426044 |
Receives reassigned benefits from 3 practitioners Practice locations: Dyersburg, TN |
National Provider Directory
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician |
207Q00000X | MD35727 | TN | Yes |
| Family Medicine Physician |
207Q00000X | MD25289 | TN | |
| Family Nurse Practitioner |
363LF0000X | APN13637 | TN |
Addresses
Primary practice location
1716 Parr Ave Ste D
Dyersburg, TN 38024-2074
Mailing address
1716 Parr Ave Ste D
Dyersburg, TN 38024-2074
Phone (731) 288-0911
Other providers in Dyersburg, TN
- Bradley Edward Gatlin
- Jeremy Wayne Gatlin
- Jill Christine Gatlin
- Geriatric Essentials, PC
- Harry Robert Gilley
- Ashten Granner
- Matthew Joseph Granner
- Daniel P Green
- Wendy Hope Greene
- Whitney Greene
All providers in Dyersburg, TN · Family Medicine Physician in Tennessee
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Oct 9, 2017. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.