Provider Demographics
NPI:1780143800
Name:EDP OF TENNESSEE PC
Entity type:Organization
Organization Name:EDP OF TENNESSEE PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF INTEGRATIONS
Authorized Official - Prefix:
Authorized Official - First Name:ROSEANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUNENKANT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-937-3619
Mailing Address - Street 1:141 W JACKSON BLVD STE 210
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60604-3048
Mailing Address - Country:US
Mailing Address - Phone:312-937-3619
Mailing Address - Fax:
Practice Address - Street 1:7938 WOLF RIVER BLVD
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-1725
Practice Address - Country:US
Practice Address - Phone:901-754-3117
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EDP OF TENNESSEE PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-03-18
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental