Provider Demographics
NPI:1407964257
Name:REAVES, EDWARD MCCORMICK (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:MCCORMICK
Last Name:REAVES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6027 WALNUT GROVE RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-2127
Mailing Address - Country:US
Mailing Address - Phone:901-683-0417
Mailing Address - Fax:901-683-4703
Practice Address - Street 1:6027 WALNUT GROVE RD
Practice Address - Street 2:SUITE 201
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-2127
Practice Address - Country:US
Practice Address - Phone:901-683-0417
Practice Address - Fax:901-683-4703
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2009-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD4575207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3382217Medicaid
061093071OtherRAILROAD MEDICARE
2005203OtherBLUE CROSS
061093071OtherRAILROAD MEDICARE
TN3382217Medicaid