Provider Demographics
NPI:1780837724
Name:GREATER MEMPHIS MOBILE MEDICAL, LLC
Entity Type:Organization
Organization Name:GREATER MEMPHIS MOBILE MEDICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AVELINO
Authorized Official - Middle Name:G
Authorized Official - Last Name:REYES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:901-685-5231
Mailing Address - Street 1:5225 GLYNBOURNE PL
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38117-4564
Mailing Address - Country:US
Mailing Address - Phone:901-685-5231
Mailing Address - Fax:
Practice Address - Street 1:5225 GLYNBOURNE PL
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38117-4564
Practice Address - Country:US
Practice Address - Phone:901-685-5231
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-03
Last Update Date:2008-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD16093207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNA73584Medicare UPIN