Provider Demographics
NPI:1649211418
Name:CARDIOVASCULAR SURGERY CLINIC, PLLC
Entity Type:Organization
Organization Name:CARDIOVASCULAR SURGERY CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HARVEY
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:GARRETT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:901-747-3066
Mailing Address - Street 1:6029 WALNUT GROVE RD
Mailing Address - Street 2:SUITE 401
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-2112
Mailing Address - Country:US
Mailing Address - Phone:901-747-3066
Mailing Address - Fax:901-747-2966
Practice Address - Street 1:6029 WALNUT GROVE RD
Practice Address - Street 2:SUITE 401
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-2112
Practice Address - Country:US
Practice Address - Phone:901-747-3066
Practice Address - Fax:901-747-2966
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-10
Last Update Date:2020-08-22
Deactivation Date:2019-02-04
Deactivation Code:
Reactivation Date:2019-04-24
Provider Licenses
StateLicense IDTaxonomies
TN17068208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3713059Medicaid
MS09016196Medicaid
AR8P057OtherBCBS GRP #
MS09016196Medicaid
AR8P057OtherBCBS GRP #