Provider Demographics
NPI:1326218868
Name:PEDIATRIC UROLOGY ASSOCIATES OF THE MID-SOUTH, P.C.
Entity Type:Organization
Organization Name:PEDIATRIC UROLOGY ASSOCIATES OF THE MID-SOUTH, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC UROLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:R
Authorized Official - Last Name:JERKINS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:901-751-0500
Mailing Address - Street 1:1920 KIRBY PKWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138-3696
Mailing Address - Country:US
Mailing Address - Phone:901-751-0500
Mailing Address - Fax:901-751-0551
Practice Address - Street 1:1920 KIRBY PKWY
Practice Address - Street 2:SUITE 100
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-3696
Practice Address - Country:US
Practice Address - Phone:901-751-0500
Practice Address - Fax:901-751-0551
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-11
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000008476261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3378412OtherMEDICARE