Provider Demographics
NPI:1366509721
Name:MEMPHIS PRIMARY CARE & WELLNESS ASSOCIATES
Entity Type:Organization
Organization Name:MEMPHIS PRIMARY CARE & WELLNESS ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LORETTA
Authorized Official - Middle Name:MOSIEJ
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-405-0275
Mailing Address - Street 1:7645 WOLF RIVER CIR STE 100
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138-1751
Mailing Address - Country:US
Mailing Address - Phone:901-405-0275
Mailing Address - Fax:901-869-2908
Practice Address - Street 1:7645 WOLF RIVER CIR STE 100
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-1751
Practice Address - Country:US
Practice Address - Phone:901-405-0275
Practice Address - Fax:901-405-0288
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2013-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical NeurophysiologyGroup - Multi-Specialty
No2084P0005XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurodevelopmental DisabilitiesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSC03068Medicare ID - Type UnspecifiedCAHABA
TN3715314Medicare ID - Type Unspecified