NPIMap

Organization Active NPI

Bradley Polk Walk in Clinic

  • Rural Health Clinic/Center
  • Ocoee, TN
National Provider Identifier
1770929333
Registry record updated Nov 8, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
BRADLEY POLK WALK IN CLINIC
Practice address
119 White Water Dr
Ocoee, TN 37361-3645
Phone
(423) 299-9435
NPI assigned
May 21, 2013
Last updated
Nov 8, 2019By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 8, 2019

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Tami Solberg Brehen, NP-CNPI 1700185469
Title
Co-Owner
Phone
(423) 299-9435

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X NU Primary
Family Nurse Practitioner 363LF0000X APN15727 TN
Internal Medicine Physician 207R00000X NU

Addresses

Primary practice location

119 White Water Dr
Ocoee, TN 37361-3645

Mailing address

119 White Water Dr
Ocoee, TN 37361-3645
Phone (423) 299-9435

Other identifiers 1

IdentifierTypeStateIssuer
Q002302MedicaidTN

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in TN2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20130925000716 TN Part B Supplier - Clinic/Group Practice 0547404931 Receives reassigned benefits from 18 practitioners
Practice locations: Ocoee, TN
O20181109001546 TN Part A Provider - Rural Health Clinic 0547404931 Practice locations: Ocoee, TN

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1770929333. Details of each certification follow.

Rural health clinic certification: CCN 448999

Legal name
BRADLEY POLK WALK IN CLINIC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Jan 9, 2019
Last certification
Jan 9, 2019
Ownership / control type
1C
Organization structure
LLCProprietary
Enrollment address
119 Whitewater Dr
Ocoee, TN 37361-3645

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
44D2060419Bradley-Polk Walk-in Clinic119 Whitewater Dr, Ocoee, TN 37361Certificate of waiverJun 10, 2027

National Provider Directory

National Provider Directory

Locations

134 Creekside Dr
Ste 4
Ocoee, TN 37361
Phone (423) 299-9435

Ownership & related parties

All disclosed owners & managing parties 4

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Harry Brehen Individual Contracted Managing EmployeePartner Jan 1, 2014 20%
5% Or Greater Direct Ownership InterestPartner Jan 1, 2014 20%
Corporate OfficerPartner Jan 1, 2014 20%
Tami Brehen Individual 5% Or Greater Direct Ownership InterestPartner Jan 1, 2014 20%
Corporate OfficerPartner Jan 1, 2014 20%
Operational/Managerial ControlPartner Jan 1, 2014 20%
Azhar S Sheikh Individual 5% Or Greater Direct Ownership InterestPartner Jan 1, 2014 40%
Corporate OfficerPartner Jan 1, 2014 40%
Operational/Managerial ControlPartner Jan 1, 2014 40%
Ahmad M. Ibrahimbacha Individual Contracted Managing EmployeePartner Jan 1, 2014 20%
5% Or Greater Direct Ownership InterestPartner Jan 1, 2014 20%
Corporate OfficerPartner Jan 1, 2014 20%

Owners & managing parties with NPI records 3

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

  • Tami Solberg Brehen, NP
    • Family Nurse Practitioner
    • Cleveland, TN
    • NPI 1700185469

    5% Or Greater Direct Ownership Interest, Corporate Officer, Operational/Managerial Control

    CMS ownership
  • Ahmad Machhour Ibrahimbacha, M,D.
    • Pulmonary Disease Physician
    • Cleveland, TN
    • NPI 1043266752

    5% Or Greater Direct Ownership Interest, Contracted Managing Employee, Corporate Officer

    CMS ownership
  • Azhar Sheikh, MD
    • Internal Medicine Physician
    • Cleveland, TN
    • NPI 1013972538

    5% Or Greater Direct Ownership Interest, Corporate Officer, Operational/Managerial Control

    CMS ownership

Practitioners & affiliated clinicians

Practitioners 22

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 22

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1369094400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1573171200000",
    "number": "1770929333",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "119 WHITE WATER DR",
            "city": "OCOEE",
            "state": "TN",
            "postal_code": "373613645",
            "telephone_number": "423-299-9435",
            "fax_number": "423-299-9436"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "119 WHITE WATER DR",
            "city": "OCOEE",
            "state": "TN",
            "postal_code": "373613645",
            "telephone_number": "423-299-9435"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BRADLEY POLK WALK IN CLINIC",
        "organizational_subpart": "NO",
        "enumeration_date": "2013-05-21",
        "last_updated": "2019-11-08",
        "status": "A",
        "authorized_official_last_name": "BREHEN",
        "authorized_official_first_name": "TAMI",
        "authorized_official_middle_name": "SOLBERG",
        "authorized_official_title_or_position": "CO-OWNER",
        "authorized_official_telephone_number": "423-299-9435",
        "authorized_official_credential": "NP-C"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "NU",
            "license": null,
            "primary": true
        },
        {
            "code": "363LF0000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Family",
            "state": "TN",
            "license": "APN15727",
            "primary": false
        },
        {
            "code": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "Q002302",
            "state": "TN"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Ocoee, TN

Sources for this page

Verify at the official NPI Registry.