Provider Demographics
NPI:1477984508
Name:MID-SOUTH CONVENIENT CARE, PLLC
Entity Type:Organization
Organization Name:MID-SOUTH CONVENIENT CARE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PANKAJ
Authorized Official - Middle Name:
Authorized Official - Last Name:SRIVASTAVA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:731-445-4987
Mailing Address - Street 1:1445 US HIGHWAY 51 BYP E
Mailing Address - Street 2:SUITE B
Mailing Address - City:DYERSBURG
Mailing Address - State:TN
Mailing Address - Zip Code:38024-2127
Mailing Address - Country:US
Mailing Address - Phone:731-286-1900
Mailing Address - Fax:731-286-1939
Practice Address - Street 1:521 HWY 51 NORTH
Practice Address - Street 2:
Practice Address - City:RIPLEY
Practice Address - State:TN
Practice Address - Zip Code:38063
Practice Address - Country:US
Practice Address - Phone:731-286-6611
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-27
Last Update Date:2017-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000034709207Q00000X
261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty