Provider Demographics
NPI: | 1780676650 |
---|---|
Name: | UT MEDICAL GROUP INC |
Entity Type: | Organization |
Organization Name: | UT MEDICAL GROUP INC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | CHIEF ADMINISTRATIVE OFFICER |
Authorized Official - Prefix: | |
Authorized Official - First Name: | COURTNEY |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | LOVE |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 901-866-8105 |
Mailing Address - Street 1: | 1407 UNION AVE STE 700 |
Mailing Address - Street 2: | |
Mailing Address - City: | MEMPHIS |
Mailing Address - State: | TN |
Mailing Address - Zip Code: | 38104-3641 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 901-866-8864 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 1407 UNION AVE STE 700 |
Practice Address - Street 2: | |
Practice Address - City: | MEMPHIS |
Practice Address - State: | TN |
Practice Address - Zip Code: | 38104-3641 |
Practice Address - Country: | US |
Practice Address - Phone: | 901-866-8864 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2005-08-17 |
Last Update Date: | 2023-04-04 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 261QM1300X | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | Group - Multi-Specialty |
No | 103TH0004X | Behavioral Health & Social Service Providers | Psychologist | Health | Group - Multi-Specialty |
No | 207N00000X | Allopathic & Osteopathic Physicians | Dermatology | Group - Multi-Specialty | |
No | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
No | 207V00000X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Group - Multi-Specialty | |
No | 207W00000X | Allopathic & Osteopathic Physicians | Ophthalmology | Group - Multi-Specialty | |
No | 207ZP0102X | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | Group - Multi-Specialty |
No | 2080N0001X | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine | Group - Multi-Specialty |
No | 2084N0400X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | Group - Multi-Specialty |
No | 2084P0800X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | Group - Multi-Specialty |
No | 2084P0802X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Addiction Psychiatry | Group - Multi-Specialty |
No | 208600000X | Allopathic & Osteopathic Physicians | Surgery | Group - Multi-Specialty | |
No | 2086S0122X | Allopathic & Osteopathic Physicians | Surgery | Plastic and Reconstructive Surgery | Group - Multi-Specialty |
No | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
TN | 1530598 | Medicaid | |
MO | 500425103 | Medicaid | |
KY | 65906117 | Medicaid | |
MS | 04721062 | Medicaid | |
AR | 107355002 | Medicaid | |
IL | 1780676650 | Medicaid | |
AL | 154277 | Medicaid | |
AR | 107355002 | Medicaid |