Provider Demographics
NPI:1962508937
Name:BRENTWOOD PEDIATRICS PLLC
Entity Type:Organization
Organization Name:BRENTWOOD PEDIATRICS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER-PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JILL
Authorized Official - Middle Name:ANDREA
Authorized Official - Last Name:FORBESS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:615-661-4256
Mailing Address - Street 1:5111 MARYLAND WAY
Mailing Address - Street 2:SUITE 301
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37024-7512
Mailing Address - Country:US
Mailing Address - Phone:615-661-4256
Mailing Address - Fax:
Practice Address - Street 1:5111 MARYLAND WAY
Practice Address - Street 2:SUITE 301
Practice Address - City:BRENTWOOD
Practice Address - State:TN
Practice Address - Zip Code:37027-7513
Practice Address - Country:US
Practice Address - Phone:615-661-4256
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2007-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
G13169Medicare UPIN