Provider Demographics
NPI:1346432010
Name:BRANDON MEDICAL GROUP PLLC
Entity Type:Organization
Organization Name:BRANDON MEDICAL GROUP PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:ALBERT
Authorized Official - Middle Name:R
Authorized Official - Last Name:BRANDON
Authorized Official - Suffix:
Authorized Official - Credentials:D O
Authorized Official - Phone:931-728-4718
Mailing Address - Street 1:482 INTERSTATE DR STE A
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:TN
Mailing Address - Zip Code:37355-3109
Mailing Address - Country:US
Mailing Address - Phone:931-728-4718
Mailing Address - Fax:
Practice Address - Street 1:482 INTERSTATE DR STE A
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:TN
Practice Address - Zip Code:37355-3109
Practice Address - Country:US
Practice Address - Phone:931-728-4718
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-15
Last Update Date:2012-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDO212207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4107876OtherBCBST
TN3730155Medicaid
TN3730155Medicaid