Healthcare Provider Details

I. General information

NPI: 1013166206
Provider Name (Legal Business Name): ANTHONY W BRANDENBURG
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/12/2008
Last Update Date: 09/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 IKE ANDERSON LN
CLINTON TN
37716-6575
US

IV. Provider business mailing address

118 IKE ANDERSON LN
CLINTON TN
37716-6575
US

V. Phone/Fax

Practice location:
  • Phone: 865-463-7151
  • Fax: 865-463-7151
Mailing address:
  • Phone: 865-463-7151
  • Fax: 865-463-7151

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number070404648
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: