Provider Demographics
NPI:1598845497
Name:MEMPHIS CHILDREN'S CLINIC, PLLC
Entity Type:Organization
Organization Name:MEMPHIS CHILDREN'S CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:M
Authorized Official - Last Name:BERTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-396-0390
Mailing Address - Street 1:1129 HALE RD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38116-6373
Mailing Address - Country:US
Mailing Address - Phone:901-396-0390
Mailing Address - Fax:901-396-3728
Practice Address - Street 1:7705 POPLAR AVE
Practice Address - Street 2:SUITE 230
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-3930
Practice Address - Country:US
Practice Address - Phone:901-755-2400
Practice Address - Fax:901-753-2768
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3382354Medicaid