Provider Demographics
NPI:1578558698
Name:MEDSOUTH HEALTHCARE PC
Entity Type:Organization
Organization Name:MEDSOUTH HEALTHCARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:W
Authorized Official - Last Name:ALRED
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:731-287-4512
Mailing Address - Street 1:1700 WOODLAWN AVE
Mailing Address - Street 2:
Mailing Address - City:DYERSBURG
Mailing Address - State:TN
Mailing Address - Zip Code:38024-2028
Mailing Address - Country:US
Mailing Address - Phone:731-287-4500
Mailing Address - Fax:731-287-4804
Practice Address - Street 1:1700 WOODLAWN AVE
Practice Address - Street 2:
Practice Address - City:DYERSBURG
Practice Address - State:TN
Practice Address - Zip Code:38024-2028
Practice Address - Country:US
Practice Address - Phone:731-287-4500
Practice Address - Fax:731-287-4804
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Not Answered207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
Not Answered207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3705380Medicaid
TN3705385Medicaid
TN3705383Medicaid
TN3705386Medicaid
TN3705388Medicaid
TN3705389Medicaid
TN3705380Medicare ID - Type Unspecified
TN3705383Medicaid
TN3705385Medicaid
TN3705389Medicaid
TN3705388Medicaid
TN3705380Medicaid