| Orange Grove Center Primary Health Care Services | |
|
615 Derby St Chattanooga TN 37404-1632 | |
| (423) 493-2905 | |
| (423) 493-2950 |
| Full Name | Orange Grove Center Primary Health Care Services |
|---|---|
| Speciality | Family Medicine |
| Location | 615 Derby St, Chattanooga, Tennessee |
| Authorized Official Name and Position | Tera Roberts (CEO) |
| Authorized Official Contact | 4234932910 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Orange Grove Center Primary Health Care Services 615 Derby St Attention: Health Informatics & Reimbursement Chattanooga TN 37404-1632 Ph: (423) 493-2906 | Orange Grove Center Primary Health Care Services 615 Derby St Chattanooga TN 37404-1632 Ph: (423) 493-2905 |
| NPI Number | 1073668653 |
|---|---|
| Provider Enumeration Date | 01/24/2007 |
| Last Update Date | 03/04/2024 |
| Medicare PECOS PAC ID | 1850299124 |
|---|---|
| Medicare Enrollment ID | O20031223000480 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1073668653 | NPI | - | NPPES |
| CH3763 | Other | TN | RR MEDICARE |
| 3070512 | Other | TN | BCBS ID |
| 3399927 | Medicaid | TN |
| Provider Name | Robert J Boehm |
|---|---|
| Provider Type | Practitioner - Internal Medicine |
| Provider Identifiers | NPI Number: 1033159793 PECOS PAC ID: 1052389657 Enrollment ID: I20040921001344 |
| Provider Name | Randy R Heisser |
|---|---|
| Provider Type | Practitioner - Emergency Medicine |
| Provider Identifiers | NPI Number: 1689620999 PECOS PAC ID: 4284672965 Enrollment ID: I20050422000305 |
| Provider Name | Patrice Vivienne Henry |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1063989150 PECOS PAC ID: 6608116512 Enrollment ID: I20190312002698 |
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