Provider Demographics
NPI:1114953239
Name:MEMPHIS SPINE CENTER
Entity Type:Organization
Organization Name:MEMPHIS SPINE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUSI
Authorized Official - Middle Name:
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-507-2225
Mailing Address - Street 1:2120 EXETER RD
Mailing Address - Street 2:SUITE 130
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138-3900
Mailing Address - Country:US
Mailing Address - Phone:901-507-2225
Mailing Address - Fax:901-507-7890
Practice Address - Street 1:2120 EXETER RD
Practice Address - Street 2:SUITE 130
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-3922
Practice Address - Country:US
Practice Address - Phone:901-507-2225
Practice Address - Fax:901-507-7890
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-23
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4092713OtherBLUE CROSS BLUE SHIELD
TN5305190001OtherCIGNA GOVERNMENT SERVICES
TN5305190001OtherCIGNA GOVERNMENT SERVICES
5305190001Medicare NSC