Common Contracts
1 similar Program Provider Agreement contracts
VACCINES FOR CHILDREN PROGRAM PROVIDER AGREEMENTProgram Provider Agreement • January 24th, 2022
FACILITY INFORMATION Facility Name: BLUFF CITY MEDICAL CENTER VFC Pin#: 821518 Facility Address: 229 HIGHWAY 19 E City: BLUFF CITY County: SULLIVAN State: TN Zip: 37618 Telephone: (423)538-5116 Fax: (423)538-8679 Shipping Address (if different than facility address): 229 HIGHWAY 19 E City: BLUFF CITY County: SULLIVAN State: TN Zip: 37618 MEDICAL DIRECTOR OR EQUIVALENT Instructions: The official VFC-registered health care provider signing the agreement must be a practitioner authorized to administer pediatric vaccines under state law, who will also be held accountable for compliance by the entire organization and its VFC providers with the responsible conditions outlined in the providerenrollment agreement. The individual listed here must sign the provider agreement. Last Name, First, MI: NEWMAN, HEATHER Title: DO Specialty:FAMILY_MEDICINE License No:0000057011 Medicaid or NPI No:Q036999/1699014068 Employer Identification Number: Email: VFC VACCINE COORDINATOR Primary Vaccine Coordinato
