Provider Demographics
NPI:1114928124
Name:COO, AUDREY W (MD)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:W
Last Name:COO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2225 UNION AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-4316
Mailing Address - Country:US
Mailing Address - Phone:901-726-1161
Mailing Address - Fax:901-726-0161
Practice Address - Street 1:2225 UNION AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-4316
Practice Address - Country:US
Practice Address - Phone:901-726-1161
Practice Address - Fax:901-726-0161
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD29587174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3814497Medicaid
TN3814496Medicare ID - Type Unspecified
TN3814497Medicaid