Healthcare Provider Details

I. General information

NPI: 1265320055
Provider Name (Legal Business Name): IMPACT PHYSICIAN GROUP, TENNESSEE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2025
Last Update Date: 07/28/2025
Certification Date: 07/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1240 S GERMANTOWN RD
GERMANTOWN TN
38138-2226
US

IV. Provider business mailing address

21 EASTBROOK BND STE 218
PEACHTREE CITY GA
30269-1546
US

V. Phone/Fax

Practice location:
  • Phone: 901-275-3300
  • Fax:
Mailing address:
  • Phone: 789-675-5599
  • Fax: 678-603-9843

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: PAUL MILLER
Title or Position: CFO
Credential: CFO
Phone: 678-967-5599