Provider Demographics
NPI:1942415245
Name:MEMPHIS PEDIATRICS PLLC
Entity Type:Organization
Organization Name:MEMPHIS PEDIATRICS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:W
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-432-1591
Mailing Address - Street 1:PO BOX 1798
Mailing Address - Street 2:DEPT 07-003
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119
Mailing Address - Country:US
Mailing Address - Phone:901-432-1591
Mailing Address - Fax:901-432-1596
Practice Address - Street 1:1255 SOUTH GERMANTOWN ROAD
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138
Practice Address - Country:US
Practice Address - Phone:901-432-1591
Practice Address - Fax:901-432-1596
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD17825208000000X
TNMD18312208000000X
TNMD28107208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
E98047Medicare UPIN
E81378Medicare UPIN
D71863Medicare UPIN
E01480Medicare UPIN
F78869Medicare UPIN