Healthcare Provider Details

I. General information

NPI: 1396321410
Provider Name (Legal Business Name): TEN BROECK TENNESSEE PHYSICIANS GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2021
Last Update Date: 03/19/2021
Certification Date: 03/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 S HOSPITAL DR
MURPHYSBORO IL
62966-3333
US

IV. Provider business mailing address

603 MAIN ST
WINDERMERE FL
34786-3548
US

V. Phone/Fax

Practice location:
  • Phone: 618-684-3156
  • Fax: 618-684-1024
Mailing address:
  • Phone: 407-876-2200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: GLENDA F GUY
Title or Position: DIRECTOR COMPLIANCE
Credential:
Phone: 931-607-6513