Perry County Medical Center Inc
Organization Active NPI Federally Qualified Health Center (FQHC) · Linden, TN
NPI 1154322303 · NPPES record last updated Feb 26, 2020
Key facts
- NPI
- 1154322303
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Federally Qualified Health Center (FQHC) 261QF0400X
- Legal business name
- PERRY COUNTY MEDICAL CENTER INC
- Practice address
- 115 E Brooklyn St
Linden, TN 37096-3515 - Phone
- (931) 589-2104
- Fax
- (931) 589-2513
- NPI assigned
- Aug 9, 2005
- Organization subpart
- No
Authorized official
- Name
- Mr. Phillip B. Tatum
- Title
- Ceo
- Phone
- (931) 589-2104
Owners & managing parties with NPI records 1
Other NPIs on the same Medicare enrollment 3
Other NPIs with the same Medicare PAC ID 2
Corporate family (same tax ID) 3
Practitioners 21
-
Amanda Deason, NP
-
Hannah Paige Dixon, FNP
-
Kristy King, FNP
-
Jeffrey Galt Smith, M.D.
-
Sherry Lynn Tidwell, FNP-BC
-
Alle Brown, FNP-C
-
Carolyn Yvonne Pulley, NURSE PRACTITIONER,
-
Cameron Ryan Baker, DDS
-
Alicia Ellis, NP
-
Derrell Thomas Seigler Jr., LPC-MHSP, MA, NCC
-
Vivian Denise Stokes, FNP-C
-
Tywanda Latrese Williams, LCSW
-
Tina Marie Evans, NP
-
Kiara Gildersleeve Johns, CRNP
-
Jewyl C Gibson, DNP, MSN, PMHNP-BC
-
Alicia Michelle Ellis, ED.D., LPC-MHSP
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 44D0307350 | Perry County Medical Center | Compliance | Jan 25, 2027 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in TN
Federally qualified health center certification: CCN 441863
- Legal name
- PERRY COUNTY MEDICAL CENTER INC
- Doing business as
- THREE RIVERS COMMUNITY HEALTH GROUP
- Certification status
- Active
- Provider type (POS)
- Federally qualified health center
- Participating since
- Apr 1, 1993
- Last certification
- Apr 1, 1993
- Ownership / control type
- For profit – corporation
- Organization structure
- Corporation · Non-profit
- Enrollment address
- 115 E Brooklyn St
Linden, TN 37096-3515
All disclosed owners & managing parties 11
| Name | Role | Since | Share |
|---|---|---|---|
| Phillip B Tatum |
Corporate Officer |
Jan 1, 2011 | |
| W-2 Managing Employee |
Jan 1, 2011 | ||
| Judy Mathis |
Corporate Director | Feb 20, 2015 | |
| Diana Richardson |
Corporate Director | Mar 31, 2015 | |
| Dean Heady |
Corporate Director | Feb 20, 2015 | |
| Margarita Austin |
Corporate Director | Feb 20, 2015 | |
| Juanest Cathey |
Corporate Director | Feb 20, 2015 | |
| Leah Conder |
Corporate Director | May 30, 2018 | |
| Betty Barber |
Corporate Director | Feb 20, 2015 | |
| Jessie R Tiller |
Corporate Director | Feb 20, 2015 | |
| Betty Culp |
Corporate Director | Mar 31, 2015 | |
| Sharon Doyle |
Corporate Director | Mar 31, 2016 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20070303000037 | TN | Part B Supplier - Clinic/Group Practice | 4981706330 |
Receives reassigned benefits from 18 practitioners 3 other NPIs on this enrollment Practice locations: Linden, TN; Lyles, TN |
| O20100621000220 | TN | Part a Provider - Federally Qualified Health Center (FQHC) | 4981706330 | Practice locations: Linden, TN |
National Provider Directory
- Tax ID family
- Perry County Medical
Locations
7723 Clearview Church Ln
Ste 2
Lyles, TN 37098
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Federally Qualified Health Center (FQHC) | 261QF0400X | Yes |
Addresses
Primary practice location
115 E Brooklyn St
Linden, TN 37096-3515
Mailing address
PO Box 916
115 East Brooklyn Street
Linden, TN 37096-0916
Phone (931) 589-2104
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 3384590 | Medicaid | TN | |
| 0443869 | Medicaid | TN |
Other providers in Linden, TN
- Perry County Community Hospital Inc
- Perry County Community Hospital Inc
- Perry County Community Hospital Inc
- Perry County Council on Aging
- Perry County Home Health, Inc.
- Perry County Medical Center, Inc.
- Keri Prater
- Mary Katelyn Pratt
- Diana Hufstedler Richardson
- Grady Ross Rowe
All providers in Linden, TN · Federally Qualified Health Center (FQHC) in Tennessee
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Feb 26, 2020. 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.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.