Provider Demographics
NPI:1891193041
Name:BOSTON MEDICAL GROUP TENNESSEE L.L.C.
Entity Type:Organization
Organization Name:BOSTON MEDICAL GROUP TENNESSEE L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CQRM
Authorized Official - Prefix:
Authorized Official - First Name:JOAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-562-4578
Mailing Address - Street 1:23275 S POINTE DRIVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653
Mailing Address - Country:US
Mailing Address - Phone:615-562-4578
Mailing Address - Fax:423-949-3992
Practice Address - Street 1:1916 PATTERSON ST
Practice Address - Street 2:SUITE 715
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37203
Practice Address - Country:US
Practice Address - Phone:615-562-4578
Practice Address - Fax:423-949-3992
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-19
Last Update Date:2014-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4878208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty