Provider Demographics
NPI:1952312431
Name:PEDIGO, PHILLIP A (MD)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:A
Last Name:PEDIGO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 EXETER RD
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138-3922
Mailing Address - Country:US
Mailing Address - Phone:901-757-3414
Mailing Address - Fax:901-757-3416
Practice Address - Street 1:2100 EXETER RD
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-3922
Practice Address - Country:US
Practice Address - Phone:901-757-3414
Practice Address - Fax:901-757-3416
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2009-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3269208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1507222Medicaid
TN4168297OtherBCBS TN
TN31192231Medicare PIN
TN1507222Medicaid