Provider Demographics
NPI:1407382492
Name:EGUOSA LLC
Entity Type:Organization
Organization Name:EGUOSA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EGUNMWENDIA
Authorized Official - Middle Name:
Authorized Official - Last Name:OGBEIDE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:901-377-7308
Mailing Address - Street 1:PO BOX 1891
Mailing Address - Street 2:
Mailing Address - City:COLLIERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38027-1891
Mailing Address - Country:US
Mailing Address - Phone:901-516-3700
Mailing Address - Fax:
Practice Address - Street 1:1300 WESLEY DR
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38116-6426
Practice Address - Country:US
Practice Address - Phone:901-516-3700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-11
Last Update Date:2017-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN207R00000X
207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical OncologyGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ02814Medicaid