Provider Demographics
NPI:1558664920
Name:M.E.M. MEDICAL SERVICES, P.C.
Entity Type:Organization
Organization Name:M.E.M. MEDICAL SERVICES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MYRON
Authorized Official - Middle Name:
Authorized Official - Last Name:MOOREHEAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-218-9002
Mailing Address - Street 1:307 GRAY SHINGLE WAY
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30189-3775
Mailing Address - Country:US
Mailing Address - Phone:770-218-9002
Mailing Address - Fax:678-384-5289
Practice Address - Street 1:200 PARKBROOKE DR
Practice Address - Street 2:SUITE 100
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30189-6331
Practice Address - Country:US
Practice Address - Phone:770-218-9002
Practice Address - Fax:678-384-5289
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-07
Last Update Date:2010-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA064985207L00000X, 207LP2900X, 2081P2900X, 208VP0000X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty