Provider Demographics
NPI:1184662579
Name:MID-SOUTH MATERNAL FETAL MEDICINE PC
Entity Type:Organization
Organization Name:MID-SOUTH MATERNAL FETAL MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:W
Authorized Official - Last Name:GIBSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-373-8949
Mailing Address - Street 1:6266 POPLAR AVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-4713
Mailing Address - Country:US
Mailing Address - Phone:901-682-2595
Mailing Address - Fax:901-682-2549
Practice Address - Street 1:6266 POPLAR AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-4713
Practice Address - Country:US
Practice Address - Phone:901-682-2595
Practice Address - Fax:901-682-2549
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-04
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR8P412OtherBCBS AR
MS07470206Medicaid
AR155822002Medicaid
TN3720439Medicaid
TN3720439Medicare PIN