Provider Demographics
NPI:1457634180
Name:DIVERSIFIED HEALTHCARE
Entity Type:Organization
Organization Name:DIVERSIFIED HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:SHREAREST
Authorized Official - Middle Name:MIGNON
Authorized Official - Last Name:CRENSHAW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:901-684-4646
Mailing Address - Street 1:6005 PARK AVE
Mailing Address - Street 2:SUITE 704
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-5202
Mailing Address - Country:US
Mailing Address - Phone:901-684-4646
Mailing Address - Fax:901-684-4650
Practice Address - Street 1:6005 PARK AVE
Practice Address - Street 2:SUITE 704
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-5202
Practice Address - Country:US
Practice Address - Phone:901-684-4646
Practice Address - Fax:901-684-4650
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-20
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN39250261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNH61549Medicare UPIN