Provider Demographics
NPI:1982103057
Name:UT MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:UT MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:BOTSCHNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-382-0393
Mailing Address - Street 1:1407 UNION AVE STE 700
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-3641
Mailing Address - Country:US
Mailing Address - Phone:901-866-8205
Mailing Address - Fax:901-302-2120
Practice Address - Street 1:6575 STAGE RD
Practice Address - Street 2:
Practice Address - City:BARTLETT
Practice Address - State:TN
Practice Address - Zip Code:38134-3809
Practice Address - Country:US
Practice Address - Phone:901-382-0393
Practice Address - Fax:901-381-1177
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-05
Last Update Date:2018-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1530598Medicaid