Provider Demographics
NPI:1316024193
Name:MID-SOUTH RECTAL CLINIC, INC.
Entity Type:Organization
Organization Name:MID-SOUTH RECTAL CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:M
Authorized Official - Last Name:FOX
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:901-362-5252
Mailing Address - Street 1:7550 LUCERNE DR
Mailing Address - Street 2:SUITE 405
Mailing Address - City:MIDDLEBURG HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44130-6588
Mailing Address - Country:US
Mailing Address - Phone:440-234-8833
Mailing Address - Fax:440-234-3313
Practice Address - Street 1:6563 STAGE OAKS DR
Practice Address - Street 2:SUITE 100
Practice Address - City:BARTLETT
Practice Address - State:TN
Practice Address - Zip Code:38134-2886
Practice Address - Country:US
Practice Address - Phone:901-362-5252
Practice Address - Fax:901-369-4775
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2016-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN36972208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK155546001Medicaid
TN3727193Medicaid
MS01702559Medicaid
MSC03583Medicare PIN
AK155546001Medicaid
MS01702559Medicaid