Provider Demographics
NPI:1083236012
Name:TEN BROECK TENNESSEE PHYSICIANS GROUP INC
Entity Type:Organization
Organization Name:TEN BROECK TENNESSEE PHYSICIANS GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, COMPLIANCE
Authorized Official - Prefix:
Authorized Official - First Name:GLENDA
Authorized Official - Middle Name:F
Authorized Official - Last Name:GUY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:931-783-2511
Mailing Address - Street 1:1 MEDICAL CENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-4294
Mailing Address - Country:US
Mailing Address - Phone:931-783-2511
Mailing Address - Fax:931-783-2550
Practice Address - Street 1:802 N 8TH ST
Practice Address - Street 2:
Practice Address - City:VANDALIA
Practice Address - State:IL
Practice Address - Zip Code:62471-1756
Practice Address - Country:US
Practice Address - Phone:618-283-1731
Practice Address - Fax:618-283-0590
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-13
Last Update Date:2020-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health