Provider Demographics
NPI:1518543248
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:BUSINESS OFFICE
Authorized Official - Prefix:
Authorized Official - First Name:KARISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:HUTSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:931-319-4231
Mailing Address - Street 1:530 PARK AVE E
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:IL
Mailing Address - Zip Code:61356-3901
Mailing Address - Country:US
Mailing Address - Phone:815-876-2004
Mailing Address - Fax:815-876-2008
Practice Address - Street 1:530 PARK AVE E
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:IL
Practice Address - Zip Code:61356-3901
Practice Address - Country:US
Practice Address - Phone:815-876-2004
Practice Address - Fax:815-876-2008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-23
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health