Provider Demographics
NPI:1861009326
Name:MIDSOUTH INDEPENDENT GROUP, PLLC
Entity Type:Organization
Organization Name:MIDSOUTH INDEPENDENT GROUP, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GROUP MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:R
Authorized Official - Last Name:BREEN
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:901-832-4494
Mailing Address - Street 1:6401 POPLAR AVE STE 604
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-4808
Mailing Address - Country:US
Mailing Address - Phone:901-474-2402
Mailing Address - Fax:901-249-4070
Practice Address - Street 1:6401 POPLAR AVE STE 604
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-4808
Practice Address - Country:US
Practice Address - Phone:901-474-2402
Practice Address - Fax:901-328-5746
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-29
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ061176Medicaid