Provider Demographics
NPI:1184854473
Name:TENNESSEE PHS PC
Entity Type:Organization
Organization Name:TENNESSEE PHS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:HOWARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-991-9276
Mailing Address - Street 1:1509 DULLES DRIVE
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70506
Mailing Address - Country:US
Mailing Address - Phone:337-991-9276
Mailing Address - Fax:337-991-9288
Practice Address - Street 1:9155 CRESTWYN HILLS DR
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38125-8501
Practice Address - Country:US
Practice Address - Phone:901-261-4858
Practice Address - Fax:901-261-4867
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROVIDER HEALTH SERVICES LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-07-21
Last Update Date:2014-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1519862Medicaid
TN103G707029Medicare PIN