Provider Demographics
NPI:1053794354
Name:BROOKWOOD PRIMARY CARE- GRAND RIVER, L.L.C.
Entity type:Organization
Organization Name:BROOKWOOD PRIMARY CARE- GRAND RIVER, L.L.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SVP, OUTPATIENT SERVICES, TENET
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:KYLE
Authorized Official - Last Name:BURTNETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-893-2902
Mailing Address - Street 1:4902 VALLEYDALE RD
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35242-4613
Mailing Address - Country:US
Mailing Address - Phone:205-980-8099
Mailing Address - Fax:205-980-2606
Practice Address - Street 1:1115 PAYTON WAY.
Practice Address - Street 2:SUITE 111
Practice Address - City:LEEDS
Practice Address - State:AL
Practice Address - Zip Code:35094
Practice Address - Country:US
Practice Address - Phone:205-352-1175
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-06
Last Update Date:2016-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty