Provider Demographics
NPI:1326229345
Name:COLLIERVILLE PEDIATRICS, LLC
Entity Type:Organization
Organization Name:COLLIERVILLE PEDIATRICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAYA
Authorized Official - Middle Name:
Authorized Official - Last Name:VENKATARAMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:901-854-5455
Mailing Address - Street 1:2028 W POPLAR AVE
Mailing Address - Street 2:SUITE 112
Mailing Address - City:COLLIERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38017-0618
Mailing Address - Country:US
Mailing Address - Phone:901-854-5455
Mailing Address - Fax:901-377-7309
Practice Address - Street 1:2028 W POPLAR AVE
Practice Address - Street 2:SUITE 112
Practice Address - City:COLLIERVILLE
Practice Address - State:TN
Practice Address - Zip Code:38017-0618
Practice Address - Country:US
Practice Address - Phone:901-854-5455
Practice Address - Fax:901-377-7309
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-19
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN38751208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNF99456Medicare UPIN