Provider Demographics
NPI:1275531220
Name:MEMPHIS ORTHOPAEDIC MEDICAL SUPPLIES,LLC.
Entity Type:Organization
Organization Name:MEMPHIS ORTHOPAEDIC MEDICAL SUPPLIES,LLC.
Other - Org Name:METRO ORTHOTICS
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
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 1:2809 KIRBY PARKWAY
Practice Address - Street 2:SUITE 105
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-8241
Practice Address - Country:US
Practice Address - Phone:901-755-4344
Practice Address - Fax:901-755-4099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
335E00000X
TN332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered335E00000XSuppliersProsthetic/Orthotic Supplier
Not Answered332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1452529Medicaid
TN3160043OtherBLUECROSS BLUESHIELD
TN3160043OtherBLUECROSS BLUESHIELD