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NPI Code Detail

MEDICARE: TEN BROECK TENNESSEE PHYSICIANS GROUP INC

MEDICARE: TEN BROECK TENNESSEE PHYSICIANS GROUP INC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1261QM0850XAdult Mental Health Clinic/Center

General Provider Information

NPI Number : 1275155418
Entity Type Code : Organization
Provider Name (Legal Business Name) : TEN BROECK TENNESSEE PHYSICIANS GROUP INC
Provider Business Mailing Address
First Line : 1 MEDICAL CENTER BLVD
Second Line :
City : COOKEVILLE
State : TN
Zip : 38501-4294
Country : US
Telephone Number : 931-783-2511
Fax Number : 931-783-2550
Provider Business Practice Location Address
First Line : 45OO MEMORIAL DRIVE
Second Line :
City : BELLEVILLE
State : IL
Zip : 62226-5399
Country : US
Telephone Number : 618-257-5900
Fax Number : 618-257-5463
Authorized Official
Title or Position : DIRECTOR, COMPLIANCE
Name : GLENDA F GUY
Credential :
Telephone Number : 931-783-2511
Provider Enumeration Date : 05/11/2020
Last Update Date : 05/11/2020

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