Provider Demographics
NPI:1609129139
Name:SOUTH MD PC
Entity Type:Organization
Organization Name:SOUTH MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:OLUWATOYIN
Authorized Official - Middle Name:JIMMY
Authorized Official - Last Name:AGBAOSI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:901-570-7438
Mailing Address - Street 1:PO BOX 16384
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38186-0384
Mailing Address - Country:US
Mailing Address - Phone:901-570-7438
Mailing Address - Fax:
Practice Address - Street 1:1300 WESLEY DR
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38116-6426
Practice Address - Country:US
Practice Address - Phone:901-570-7438
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-22
Last Update Date:2016-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1530261Medicaid
TN103G702631Medicare PIN