Provider Demographics
NPI:1811046345
Name:MEDICAL GROUP - SOUTHERN HILLS OF BRENTWOOD LLC
Entity type:Organization
Organization Name:MEDICAL GROUP - SOUTHERN HILLS OF BRENTWOOD LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:
Authorized Official - Last Name:RYDBURG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-373-7615
Mailing Address - Street 1:317 SEVEN SPRINGS WAY
Mailing Address - Street 2:SUITE 104
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027
Mailing Address - Country:US
Mailing Address - Phone:615-377-4999
Mailing Address - Fax:615-377-8830
Practice Address - Street 1:317 SEVEN SPRINGS WAY
Practice Address - Street 2:SUITE 104
Practice Address - City:BRENTWOOD
Practice Address - State:TN
Practice Address - Zip Code:37027
Practice Address - Country:US
Practice Address - Phone:615-377-4999
Practice Address - Fax:615-377-8830
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-10
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3370012Medicaid
TN3370012Medicare PIN
DS9017Medicare PIN