Family Medicine West PLLC
Organization Active NPI Rural Health Clinic/Center · Wartburg, TN
NPI 1902292865 · NPPES record last updated Apr 7, 2015
Key facts
- NPI
- 1902292865
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Rural Health Clinic/Center 261QR1300X
- Legal business name
- FAMILY MEDICINE WEST PLLC
- Practice address
- 1236 Knoxville Hwy
Suite 500
Wartburg, TN 37887-4200 - Phone
- (423) 346-5566
- Fax
- (423) 346-5631
- NPI assigned
- Apr 7, 2015
- Organization subpart
- No
Authorized official
- Name
- Dr. Sanjay P Thankur, M.D.
- Title
- MD/President
- Phone
- (423) 346-5566
Owners & managing parties with NPI records 1
-
Sanjay P Thakur, M.D.
Other NPIs with the same Medicare PAC ID 1
Practitioners 28
-
Robert Dowell, FNP
-
Amber Dawn Gamblin, FNP-C
-
Katherine Gresham, FNP
-
Mary Ann Hammonds, MSN ADULT NURSE PRA
-
Jaan Kelly, PA-C
-
Jonna Leeann Pittman, PA-C
-
Sanjay P Thakur, M.D.
-
Jennifer Robin Green, FNP
-
Emily Marie Lee, FNP-C
-
Naveen Mohyuddin, PA-C
-
Shastina Parahoo, PA
-
Amanda Bailey Parks, FNP
-
Johnny Ray Rivers, FNP
-
Kevin Eric Stasney, M.D.
-
Marcia E. Jacobs, F.N.P. - B.C.
-
Derek Riseden, FNP-BC, NP-C
-
Jennifer Clark Riseden, FNP-BC
-
Davida Yvonne Asbury, FNP-C
-
Robert E Bledsoe Jr., M.D.
-
Patti A Harris, CNM
-
Joseph C Lauterbach, M.D.
-
Jennifer Ann Lipps, CNM
-
Thomas W McDonald, M.D.
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 44D2048018 | Family Medicine West, PLLC | Certificate of waiver | Oct 7, 2026 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in TN
Rural health clinic certification: CCN 448952
- Legal name
- FAMILY MEDICINE WEST PLLC
- Doing business as
- FAMILY MEDICINE WEST OF WARTBURG
- Certification status
- Active
- Provider type (POS)
- Rural health clinic
- Participating since
- Aug 24, 2015
- Last certification
- Dec 7, 2021
- Ownership / control type
- 1A
- Organization structure
- LLC · Proprietary
- Incorporated
- Jul 25, 2012 in TN
- Enrollment address
- 1236 Knoxville Highway
Suite 500
Wartburg, TN 37887-4200
All disclosed owners & managing parties 1
| Name | Role | Since | Share |
|---|---|---|---|
| Sanjay P Thakur |
5% Or Greater Direct Ownership Interest | Jul 25, 2012 | 100% |
| Corporate Director |
Jul 25, 2012 | 100% | |
| W-2 Managing Employee | Jul 25, 2012 | 100% | |
| Operational/Managerial Control |
Jul 25, 2012 | 100% |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20150615001198 | TN | Part a Provider - Rural Health Clinic | 7618126608 | Practice locations: Wartburg, TN |
National Provider Directory
Locations
220 Fort Sanders West Blvd
Ste 200
Knoxville, TN 37922
Phone (423) 346-5566
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Rural Health Clinic/Center | 261QR1300X | TN | Yes |
Addresses
Primary practice location
1236 Knoxville Hwy
Suite 500
Wartburg, TN 37887-4200
Mailing address
220 Fort Sanders West Blvd
Building 2, Suite 200
Knoxville, TN 37922-3398
Phone (423) 346-5566
Other names
- Family Medicine West of Wartburg
Other providers in Wartburg, TN
- Mansour Daoud
- Caitlyn Davis
- Laura Sue Delgado-Evensen
- Mahogani Eaton
- Leslie L El-Sayad
- James Brad Farmer
- Kendra L Flowers
- Mary Foster
- Addie L Freytag
- Joseph Sean Galloway
All providers in Wartburg, TN · Rural Health Clinic/Center in Tennessee
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Apr 7, 2015. 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.