Provider Demographics
NPI:1073668653
Name:ORANGE GROVE CENTER, INC.
Entity Type:Organization
Organization Name:ORANGE GROVE CENTER, INC.
Other - Org Name:ORANGE GROVE CENTER PRIMARY HEALTH CARE SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:TERA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-493-2910
Mailing Address - Street 1:615 DERBY ST
Mailing Address - Street 2:ATTENTION: HEALTH INFORMATICS & REIMBURSEMENT
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37404-1632
Mailing Address - Country:US
Mailing Address - Phone:423-493-2906
Mailing Address - Fax:423-493-2950
Practice Address - Street 1:615 DERBY ST
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37404-1632
Practice Address - Country:US
Practice Address - Phone:423-493-2905
Practice Address - Fax:423-493-2950
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ORANGE GROVE CENTER, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-24
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN86861223G0001X
TN26723207QA0505X
TN13774363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNCH3763OtherRR MEDICARE
TN3070512OtherBCBS ID
TN3399927Medicaid
TN3399927Medicare PIN