NPIMap

Organization Active NPI

Marvel Clinic P.C.

  • Specialist
  • Tullahoma, TN
National Provider Identifier
1760487086
Registry record updated Aug 22, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
SpecialistTaxonomy code 174400000X
Legal business name
MARVEL CLINIC P.C.
Practice address
1821 N Washington St
Tullahoma, TN 37388-2221
Phone
(931) 455-2005
Fax
(931) 455-4450
NPI assigned
Jun 14, 2005
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 22, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Tracy Dawn Wilkins
Title
Credentialing Facilitator
Phone
(931) 461-5056

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
SpecialistGroup: 193400000X SINGLE SPECIALTY GROUP 174400000X TN Primary

Addresses

Primary practice location

1821 N Washington St
Tullahoma, TN 37388-2221

Mailing address

1821 N Washington St
Tullahoma, TN 37388-2221
Phone (931) 455-2005

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in TN

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20101101000063 TN Part B Supplier - Clinic/Group Practice 0547454811 Receives reassigned benefits from 10 practitioners
Practice locations: Tullahoma, TN

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
44D0309776Marvel Clinic PC1821 North Washington Street, Tullahoma, TN 37388Certificate of waiverSep 2, 2026

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 11

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1118707200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1760487086",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1821 N WASHINGTON ST",
            "city": "TULLAHOMA",
            "state": "TN",
            "postal_code": "373882221",
            "telephone_number": "931-455-2005",
            "fax_number": "931-455-4450"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1821 N WASHINGTON ST",
            "city": "TULLAHOMA",
            "state": "TN",
            "postal_code": "373882221",
            "telephone_number": "931-455-2005",
            "fax_number": "931-455-4450"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MARVEL CLINIC P.C.",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-06-14",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "WILKINS",
        "authorized_official_first_name": "TRACY",
        "authorized_official_middle_name": "DAWN",
        "authorized_official_title_or_position": "CREDENTIALING FACILITATOR",
        "authorized_official_telephone_number": "931-461-5056"
    },
    "taxonomies": [
        {
            "code": "174400000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Specialist",
            "state": "TN",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Tullahoma, TN

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.