Provider Demographics
NPI:1437449170
Name:MEMPHIS PAIN MANAGEMENT GROUP, PC
Entity Type:Organization
Organization Name:MEMPHIS PAIN MANAGEMENT GROUP, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:D
Authorized Official - Last Name:RADICAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-682-5335
Mailing Address - Street 1:6100 PRIMACY PKWY
Mailing Address - Street 2:SUITE 112
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-0705
Mailing Address - Country:US
Mailing Address - Phone:901-682-5335
Mailing Address - Fax:
Practice Address - Street 1:6100 PRIMACY PKWY
Practice Address - Street 2:SUITE 112
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-0705
Practice Address - Country:US
Practice Address - Phone:901-682-5335
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-14
Last Update Date:2013-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDC1171111N00000X
TNMD430532207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNU54784Medicare UPIN