Provider Demographics
NPI:1225159643
Name:PEDIATRIC RADIOLOGY
Entity Type:Organization
Organization Name:PEDIATRIC RADIOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING
Authorized Official - Prefix:
Authorized Official - First Name:TONYA
Authorized Official - Middle Name:
Authorized Official - Last Name:MALADY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-737-3071
Mailing Address - Street 1:806 ESTATE PL
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38148-0001
Mailing Address - Country:US
Mailing Address - Phone:901-737-3071
Mailing Address - Fax:
Practice Address - Street 1:806 ESTATE PL
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38148-0001
Practice Address - Country:US
Practice Address - Phone:901-737-3071
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD63552085P0229X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3000746Medicaid
=========OtherTAX ID NUMBER
30000743Medicare ID - Type UnspecifiedMEDICARE INDV ID NUMBER
3382786Medicare ID - Type UnspecifiedMEDICARE GROUP ID
TN3000746Medicaid