Provider Demographics
NPI:1144392127
Name:UROLOGY OF MEMPHIS, PLLC
Entity Type:Organization
Organization Name:UROLOGY OF MEMPHIS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RICKY
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:901-373-8333
Mailing Address - Street 1:PO BOX 1000
Mailing Address - Street 2:DEPT. 221
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38148-0001
Mailing Address - Country:US
Mailing Address - Phone:901-821-0338
Mailing Address - Fax:901-821-0384
Practice Address - Street 1:2996 KATE BOND
Practice Address - Street 2:SUITE 307
Practice Address - City:BARTLETT
Practice Address - State:TN
Practice Address - Zip Code:38133
Practice Address - Country:US
Practice Address - Phone:901-373-8333
Practice Address - Fax:901-373-9420
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2012-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD15982174400000X
174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1521990Medicaid
TN1521990Medicaid