Provider Demographics
NPI:1437101821
Name:WESLEY NEUROLOGY CLINIC PC
Entity Type:Organization
Organization Name:WESLEY NEUROLOGY CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:R
Authorized Official - Last Name:LUCAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-725-8920
Mailing Address - Street 1:PO BOX 1885
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38101-1885
Mailing Address - Country:US
Mailing Address - Phone:901-725-8920
Mailing Address - Fax:901-725-8936
Practice Address - Street 1:1211 UNION AVE
Practice Address - Street 2:STE 400
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104
Practice Address - Country:US
Practice Address - Phone:901-725-8920
Practice Address - Fax:901-725-8936
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2008-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3703205Medicaid
MS09013571Medicaid
AR122543002Medicaid
MS09013571Medicaid