| Executive Outcomes Pc | |
|
560 Mcclellan Rd Jackson TN 38305-9688 | |
| (731) 234-5717 | |
| (423) 979-6333 |
| Full Name | Executive Outcomes Pc |
|---|---|
| Speciality | Internal Medicine |
| Location | 560 Mcclellan Rd, Jackson, Tennessee |
| Authorized Official Name and Position | Monico P Banez (OWNER) |
| Authorized Official Contact | 7312345717 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Executive Outcomes Pc 560 Mcclellan Rd Jackson TN 38305-9688 Ph: (731) 234-5717 | Executive Outcomes Pc 560 Mcclellan Rd Jackson TN 38305-9688 Ph: (731) 234-5717 |
| NPI Number | 1821352808 |
|---|---|
| Provider Enumeration Date | 06/25/2012 |
| Last Update Date | 02/24/2015 |
| Medicare PECOS PAC ID | 8426200734 |
|---|---|
| Medicare Enrollment ID | O20121213000329 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1821352808 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207R00000X | Internal Medicine | (* (Not Available)) | Primary |
| Provider Name | Maria C Antique |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1245278415 PECOS PAC ID: 9234115619 Enrollment ID: I20040626000040 |
| Provider Name | Martinson Ansah |
|---|---|
| Provider Type | Practitioner - Internal Medicine |
| Provider Identifiers | NPI Number: 1629033246 PECOS PAC ID: 9234100322 Enrollment ID: I20080508000247 |
| Provider Name | Monico Banez |
|---|---|
| Provider Type | Practitioner - Internal Medicine |
| Provider Identifiers | NPI Number: 1962479451 PECOS PAC ID: 6406996008 Enrollment ID: I20091211000468 |
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