Provider Demographics
NPI:1396321410
Name:TEN BROECK TENNESSEE PHYSICIANS GROUP INC
Entity type:Organization
Organization Name:TEN BROECK TENNESSEE PHYSICIANS GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR COMPLIANCE
Authorized Official - Prefix:
Authorized Official - First Name:GLENDA
Authorized Official - Middle Name:F
Authorized Official - Last Name:GUY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:931-607-6513
Mailing Address - Street 1:603 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WINDERMERE
Mailing Address - State:FL
Mailing Address - Zip Code:34786-3548
Mailing Address - Country:US
Mailing Address - Phone:407-876-2200
Mailing Address - Fax:
Practice Address - Street 1:2 S HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:MURPHYSBORO
Practice Address - State:IL
Practice Address - Zip Code:62966-3333
Practice Address - Country:US
Practice Address - Phone:618-684-3156
Practice Address - Fax:618-684-1024
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-19
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health