Provider Demographics
NPI:1073539938
Name:THE FAMILY PHYSICIAN GROUP PC
Entity Type:Organization
Organization Name:THE FAMILY PHYSICIAN GROUP PC
Other - Org Name:HERMAN WESLEY DYKES JR DO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ANGIE
Authorized Official - Middle Name:
Authorized Official - Last Name:QUALLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-751-5514
Mailing Address - Street 1:2859 VAN LEER DR
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38133-4935
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7685 WINCHESTER RD STE 101
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38125-2202
Practice Address - Country:US
Practice Address - Phone:901-260-9300
Practice Address - Fax:901-751-5541
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-14
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3926223332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site
Provider Identifiers
StateIdentifier IDID TypeIssuer
4439154OtherOTHER ID NUMBER-COMMERCIAL NUMBER
4439154OtherOTHER ID NUMBER