Healthcare Provider Details

I. General information

NPI: 1053794354
Provider Name (Legal Business Name): BROOKWOOD PRIMARY CARE- GRAND RIVER, L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2015
Last Update Date: 05/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1115 PAYTON WAY. SUITE 111
LEEDS AL
35094
US

IV. Provider business mailing address

4902 VALLEYDALE RD
BIRMINGHAM AL
35242-4613
US

V. Phone/Fax

Practice location:
  • Phone: 205-352-1175
  • Fax:
Mailing address:
  • Phone: 205-980-8099
  • Fax: 205-980-2606

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. MICHAEL KYLE BURTNETT
Title or Position: SVP, OUTPATIENT SERVICES, TENET
Credential:
Phone: 469-893-2902