Provider Demographics
NPI:1366510679
Name:BROOKHAVEN MEDICAL CLINIC PC
Entity type:Organization
Organization Name:BROOKHAVEN MEDICAL CLINIC PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SANDY
Authorized Official - Middle Name:BASTIN
Authorized Official - Last Name:HOLMES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:901-767-3030
Mailing Address - Street 1:711 BROOKHAVE CIRCLE WEST
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38117
Mailing Address - Country:US
Mailing Address - Phone:901-767-3030
Mailing Address - Fax:901-767-3929
Practice Address - Street 1:711 BROOKHAVE CIRCLE WEST
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38117
Practice Address - Country:US
Practice Address - Phone:901-767-3030
Practice Address - Fax:901-767-3929
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000006842207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
3179259Medicare ID - Type Unspecified
B03859Medicare UPIN