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General NPI Number Information
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NPI Number | 1164008553
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Entity Type | Organization
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Legal Business Name | TEN BROECK TENNESSEE PHYSICIANS GROUP INC
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Dates
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Enumeration Date | 03/24/2021
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Last Update Date | 03/24/2021
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Provider Practice Location Address
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Address Line | 911 N SHELBY ST
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City | SALEM
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State | IN
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Zip | 47167-2304
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Country | US
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Telephone | 812-883-8583
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Fax | 812-883-8595
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Provider Business Mailing Address
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Address Line | 911 N SHELBY ST
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City | SALEM
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State | IN
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Zip | 47167-2304
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Country | US
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Telephone | 812-883-8583
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Fax | 812-883-8595
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Authorized Official
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Title or Position | BUSINESS OFFICE
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Name | KARISSA HUTSON
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Credential |
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Telephone | 931-319-4231
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number |
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License Number State |
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