Provider Demographics
NPI:1669508305
Name:SPECIALTY ORTHOPEDICS PC
Entity Type:Organization
Organization Name:SPECIALTY ORTHOPEDICS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:L
Authorized Official - Last Name:ENNIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:901-682-9161
Mailing Address - Street 1:5220 PARK AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-3540
Mailing Address - Country:US
Mailing Address - Phone:901-682-9161
Mailing Address - Fax:901-767-9584
Practice Address - Street 1:5220 PARK AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-3540
Practice Address - Country:US
Practice Address - Phone:901-682-9161
Practice Address - Fax:901-767-9584
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2016-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN7341174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4226930001Medicare NSC
TN3370474Medicare ID - Type Unspecified