Provider Demographics
NPI:1104374412
Name:MEMPHIS SPINE AND SPORT, PLLC
Entity Type:Organization
Organization Name:MEMPHIS SPINE AND SPORT, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:MAZAS
Authorized Official - Last Name:HOGAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:901-752-4300
Mailing Address - Street 1:1740 N GERMANTOWN PKWY
Mailing Address - Street 2:SUITE 6
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38016-3307
Mailing Address - Country:US
Mailing Address - Phone:901-752-4300
Mailing Address - Fax:901-244-7072
Practice Address - Street 1:1740 N GERMANTOWN PKWY
Practice Address - Street 2:SUITE 6
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38016-3307
Practice Address - Country:US
Practice Address - Phone:901-752-4300
Practice Address - Fax:901-244-7072
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-15
Last Update Date:2018-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2912111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty