Provider Demographics
NPI:1598176687
Name:FAMILY MEDICINE & WEIGHT LOSS MD PLLC
Entity Type:Organization
Organization Name:FAMILY MEDICINE & WEIGHT LOSS MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:HAIQIU
Authorized Official - Middle Name:E
Authorized Official - Last Name:WANG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:901-842-1473
Mailing Address - Street 1:420 S GERMANTOWN PKWY
Mailing Address - Street 2:SUITE 105B
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38018-4387
Mailing Address - Country:US
Mailing Address - Phone:901-842-1473
Mailing Address - Fax:
Practice Address - Street 1:420 S GERMANTOWN PKWY
Practice Address - Street 2:SUITE 105B
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38018-4387
Practice Address - Country:US
Practice Address - Phone:901-842-1473
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-12
Last Update Date:2014-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN37771207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN6012116OtherBCBS
TN3895476Medicare PIN