Provider Demographics
NPI:1083637078
Name:BROOKSIDE MEDICAL CENTER PLLC
Entity Type:Organization
Organization Name:BROOKSIDE MEDICAL CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SHIRLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:SPEARS
Authorized Official - Suffix:
Authorized Official - Credentials:MS, ANP, BC
Authorized Official - Phone:423-238-0033
Mailing Address - Street 1:PO BOX 793
Mailing Address - Street 2:
Mailing Address - City:OOLTEWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37363-0793
Mailing Address - Country:US
Mailing Address - Phone:423-238-0033
Mailing Address - Fax:
Practice Address - Street 1:5121 OOLTEWAH RINGGOLD ROAD
Practice Address - Street 2:SUITE G
Practice Address - City:COLLEGEDALE
Practice Address - State:TN
Practice Address - Zip Code:37315
Practice Address - Country:US
Practice Address - Phone:423-238-0033
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2009-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3735307Medicaid
TN3735307Medicare PIN