Provider Demographics
NPI:1083630560
Name:GERMANTOWN INTERNAL MEDICINE ASSOCIATES,PC
Entity Type:Organization
Organization Name:GERMANTOWN INTERNAL MEDICINE ASSOCIATES,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:F
Authorized Official - Last Name:EDMISTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-340-6777
Mailing Address - Street 1:PO BOX 2121
Mailing Address - Street 2:DEPT 1298
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38159-0001
Mailing Address - Country:US
Mailing Address - Phone:901-348-6487
Mailing Address - Fax:901-791-0338
Practice Address - Street 1:7645 WOLF RIVER CIR
Practice Address - Street 2:SUITE 202
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-1751
Practice Address - Country:US
Practice Address - Phone:901-348-6487
Practice Address - Fax:901-791-0338
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-15
Last Update Date:2008-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD027101207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3711639TMedicaid
TN3711639TMedicaid