Basic Information
| Provider Information | |||||||||
| NPI: | 1336643121 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UT MEDICAL GROUP, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | DEPT #93 | ||||||||
| Address2: | PO BOX 1000 | ||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381480093 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9018668205 | ||||||||
| FaxNumber: | 9013022120 | ||||||||
| Practice Location | |||||||||
| Address1: | 995 S YATES RD STE 2 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381190882 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9017675620 | ||||||||
| FaxNumber: | 9017634326 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2018 | ||||||||
| LastUpdateDate: | 07/24/2019 | ||||||||
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| AuthorizedOfficialLastName: | BOTSCHNER | ||||||||
| AuthorizedOfficialFirstName: | ANDREW | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9013820393 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | UT MEDICAL GROUP, INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist |
No ID Information.