Provider Demographics
NPI:1407425747
Name:BRENTWOOD PEDIATRIC CARE PLLC
Entity Type:Organization
Organization Name:BRENTWOOD PEDIATRIC CARE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JILL
Authorized Official - Middle Name:SAUSER
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-779-6167
Mailing Address - Street 1:6001 BELLE RIVE DR
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-5703
Mailing Address - Country:US
Mailing Address - Phone:630-779-6167
Mailing Address - Fax:
Practice Address - Street 1:343 FRANKLIN ROAD
Practice Address - Street 2:SUITE 106
Practice Address - City:BRENTWOOD
Practice Address - State:TN
Practice Address - Zip Code:37027-5250
Practice Address - Country:US
Practice Address - Phone:615-814-4500
Practice Address - Fax:615-814-4501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-22
Last Update Date:2021-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty