Provider Demographics
NPI:1275865677
Name:OBGYN ASSOCIATES OF THE MIDSOUTH, PLLC
Entity Type:Organization
Organization Name:OBGYN ASSOCIATES OF THE MIDSOUTH, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:S
Authorized Official - Last Name:BRONSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:901-791-9800
Mailing Address - Street 1:6215 HUMPHREYS BLVD.
Mailing Address - Street 2:SUITE 400
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-2382
Mailing Address - Country:US
Mailing Address - Phone:901-791-9800
Mailing Address - Fax:901-791-9801
Practice Address - Street 1:6215 HUMPHREYS BLVD.
Practice Address - Street 2:SUITE 400
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-2382
Practice Address - Country:US
Practice Address - Phone:901-791-9800
Practice Address - Fax:901-791-9801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-10
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207V00000X
TN207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNA97703Medicare UPIN