Provider Demographics
NPI:1902831217
Name:EXTENDCARE MEDICAL GROUP PLLC
Entity Type:Organization
Organization Name:EXTENDCARE MEDICAL GROUP PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:DENNIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:615-261-9106
Mailing Address - Street 1:2000 MALLORY LN STE 130-256
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37067-8209
Mailing Address - Country:US
Mailing Address - Phone:615-261-9106
Mailing Address - Fax:615-261-9106
Practice Address - Street 1:2000 MALLORY LN STE 130-256
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:TN
Practice Address - Zip Code:37067-8209
Practice Address - Country:US
Practice Address - Phone:615-261-9106
Practice Address - Fax:615-261-9106
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-12
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN37294207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3885918Medicaid
TNH96142Medicare UPIN
TN3885918Medicaid