Provider Demographics
NPI:1578804142
Name:BMG FAMILY PHYSICIANS GROUP FOUNDATION, INC
Entity Type:Organization
Organization Name:BMG FAMILY PHYSICIANS GROUP FOUNDATION, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:DUCKETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-227-4068
Mailing Address - Street 1:2859 VAN LEER DR
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38133-4935
Mailing Address - Country:US
Mailing Address - Phone:901-751-5513
Mailing Address - Fax:901-751-5540
Practice Address - Street 1:2859 VAN LEER DR
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38133-4935
Practice Address - Country:US
Practice Address - Phone:901-751-5513
Practice Address - Fax:901-751-5540
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-07
Last Update Date:2013-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN24112207Q00000X
TN05911225100000X
TN1314363A00000X
TN17471363LA2200X
TN17737363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN103G706623Medicare PIN