Provider Demographics
NPI:1437105277
Name:SOUTHEASTERN EMERGENCY PHYSICIANS OF MEMPHIS LLC
Entity Type:Organization
Organization Name:SOUTHEASTERN EMERGENCY PHYSICIANS OF MEMPHIS LLC
Other - Org Name:S E EMERGENCY PHYS MEMPHIS
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:CORVINI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:865-293-5205
Mailing Address - Street 1:PO BOX 633819
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-3819
Mailing Address - Country:US
Mailing Address - Phone:888-203-1274
Mailing Address - Fax:
Practice Address - Street 1:1 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-6722
Practice Address - Country:US
Practice Address - Phone:618-463-7474
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-25
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN207P00000X, 207PP0204X
363A00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No207PP0204XAllopathic & Osteopathic PhysiciansEmergency MedicinePediatric Emergency MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200924580AMedicaid
MO507218402Medicaid
KY65919342Medicaid
AR158441002Medicaid
KS200533140AMedicaid
TN3728394Medicaid
AL529932817Medicaid
KY65909962Medicaid
AR158441002Medicaid
TN3728394Medicare PIN
KS200533140AMedicaid
TN3728394Medicaid
KY65919342Medicaid
MOX950000Medicare PIN