MEDICARE: BMG FAMILY PHYSICIANS GROUP FOUNDATION, 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
1	363LF0000X	Family Nurse Practitioner	17737	TN
2	363A00000X	Physician Assistant	1314	TN
3	363LA2200X	Adult Health Nurse Practitioner	17471	TN
4	225100000X	Physical Therapist	05911	TN
5	207Q00000X	Family Medicine Physician	24112	TN

General Provider Information

NPI Number	:	1578804142
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BMG FAMILY PHYSICIANS GROUP FOUNDATION, INC

Provider Business Mailing Address
First Line	:	2859 VAN LEER DR
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38133-4935
Country	:	US
Telephone Number	:	901-751-5513
Fax Number	:	901-751-5540

Provider Business Practice Location Address
First Line	:	2859 VAN LEER DR
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38133-4935
Country	:	US
Telephone Number	:	901-751-5513
Fax Number	:	901-751-5540

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	GREGORY DUCKETT
Credential	:
Telephone Number	:	901-227-4068

Provider Enumeration Date	:	03/07/2013
Last Update Date	:	08/21/2013

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