Provider Demographics
NPI:1518248202
Name:ENT AMBULATORY CARE CENTER OF MEMPHIS, INC.
Entity Type:Organization
Organization Name:ENT AMBULATORY CARE CENTER OF MEMPHIS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDE
Authorized Official - Middle Name:H
Authorized Official - Last Name:LAZAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:901-821-4317
Mailing Address - Street 1:27087 GRATIOT AVE
Mailing Address - Street 2:2ND FL
Mailing Address - City:ROSEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48066-2985
Mailing Address - Country:US
Mailing Address - Phone:586-498-9440
Mailing Address - Fax:586-498-9460
Practice Address - Street 1:791 ESTATE PL
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-0600
Practice Address - Country:US
Practice Address - Phone:901-821-4317
Practice Address - Fax:901-821-4373
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-08
Last Update Date:2011-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center