Provider Demographics
NPI:1346219342
Name:MID-SOUTH NEPHROLOGY CONSULTANTS PLLC
Entity Type:Organization
Organization Name:MID-SOUTH NEPHROLOGY CONSULTANTS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:DOMINGA
Authorized Official - Middle Name:
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-565-0244
Mailing Address - Street 1:6490 MOUNT MORIAH ROAD EXT STE 200
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38115-3841
Mailing Address - Country:US
Mailing Address - Phone:901-565-0244
Mailing Address - Fax:901-565-0616
Practice Address - Street 1:6490 MOUNT MORIAH ROAD EXT STE 200
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38115-3841
Practice Address - Country:US
Practice Address - Phone:901-565-0244
Practice Address - Fax:901-565-0616
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-14
Last Update Date:2012-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO208992305Medicaid
TN3373435Medicaid
AR5B527OtherBLUE CROSS BLUE SHIELD
AR152287002Medicaid
TN4030327OtherBLUE CROSS BLUE SHIELD
MS09983030Medicaid
MS09983030Medicaid
TN3373435Medicaid
MSC02667Medicare ID - Type Unspecified