Provider Demographics
NPI:1760551832
Name:PRIMARY CARE SPECIALISTS
Entity Type:Organization
Organization Name:PRIMARY CARE SPECIALISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARY ELLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-567-3414
Mailing Address - Street 1:PO BOX 1726
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38101-1726
Mailing Address - Country:US
Mailing Address - Phone:901-515-4842
Mailing Address - Fax:901-458-0405
Practice Address - Street 1:3109 WALNUT GROVE ROAD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38111-3509
Practice Address - Country:US
Practice Address - Phone:901-515-4842
Practice Address - Fax:901-458-0405
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0966550001OtherDMEM
TN3703214Medicaid
TN0966550001OtherDMEM