Provider Demographics
NPI:1417604174
Name:BRANDON MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:BRANDON MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TERRENCE
Authorized Official - Middle Name:
Authorized Official - Last Name:BRANDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-743-8036
Mailing Address - Street 1:3766 CHAPEL CV
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135-2885
Mailing Address - Country:US
Mailing Address - Phone:770-892-8332
Mailing Address - Fax:470-401-1105
Practice Address - Street 1:3766 CHAPEL CV
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-2885
Practice Address - Country:US
Practice Address - Phone:770-892-8332
Practice Address - Fax:470-401-1105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-03
Last Update Date:2022-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA060-R-2073OtherHEALTHCARE FACILITY REGULATION