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General NPI Number Information
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NPI Number | 1356704357
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Entity Type | Organization
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Legal Business Name | PONTCHARTRAIN MEDICAL GROUP, A PROFESSIONAL CORPORATION
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Dates
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Enumeration Date | 03/29/2016
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Last Update Date | 08/25/2021
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Provider Practice Location Address
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Address Line | 200 POWELL PL ATTN: LEGAL DEPARTMENT
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City | BRENTWOOD
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State | TN
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Zip | 37027-7514
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Country | US
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Telephone | 615-732-1605
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Fax |
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Provider Business Mailing Address
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Address Line | 200 POWELL PL ATTN: LEGAL DEPARTMENT
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City | BRENTWOOD
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State | TN
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Zip | 37027-7514
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Country | US
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Telephone | 615-732-1605
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | MARK A CALARCO
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Credential | DO
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Telephone | 615-712-5862
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RA0401X
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Taxonomy Name | Addiction Medicine (Internal Medicine) Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 2084A0401X
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Taxonomy Name | Addiction Medicine (Psychiatry & Neurology) Physician
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License Number |
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License Number State |
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