Provider Demographics
NPI:1215030796
Name:MEMPHIS ORTHOPAEDIC MEDICAL SUPPLIES, LLC
Entity Type:Organization
Organization Name:MEMPHIS ORTHOPAEDIC MEDICAL SUPPLIES, LLC
Other - Org Name:METRO ORTHOTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GUY
Authorized Official - Middle Name:FRED
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:CO
Authorized Official - Phone:901-755-4344
Mailing Address - Street 1:2809 KIRBY PARKWAY
Mailing Address - Street 2:SUITE 105
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-8241
Mailing Address - Country:US
Mailing Address - Phone:901-755-4344
Mailing Address - Fax:901-755-4099
Practice Address - Street 1:701 EAST REELFOOT AVENUE
Practice Address - Street 2:SUITE 500
Practice Address - City:UNION CITY
Practice Address - State:TN
Practice Address - Zip Code:38261
Practice Address - Country:US
Practice Address - Phone:901-884-0284
Practice Address - Fax:901-884-0281
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Not Answered335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1452529Medicaid
TN1319070002Medicare ID - Type Unspecified