Provider Demographics
NPI:1619138377
Name:PERRY C. ROTHROCK III, M.D. PLLC
Entity Type:Organization
Organization Name:PERRY C. ROTHROCK III, M.D. PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PERRY
Authorized Official - Middle Name:CLYDE
Authorized Official - Last Name:ROTHROCK
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:901-757-9984
Mailing Address - Street 1:8309 CORDOVA RD
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38016-2046
Mailing Address - Country:US
Mailing Address - Phone:901-757-9984
Mailing Address - Fax:901-757-0536
Practice Address - Street 1:8309 CORDOVA RD
Practice Address - Street 2:
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38016-2046
Practice Address - Country:US
Practice Address - Phone:901-757-9984
Practice Address - Fax:901-757-0536
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-24
Last Update Date:2015-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN37500207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3729650Medicare PIN
TNG02590Medicare UPIN