Provider Demographics
NPI:1003855420
Name:COLLIERVILLE ORTHOPEDICS AND
Entity type:Organization
Organization Name:COLLIERVILLE ORTHOPEDICS AND
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DEDE
Authorized Official - Middle Name:
Authorized Official - Last Name:COKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-850-1150
Mailing Address - Street 1:PO BOX 9616
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-9616
Mailing Address - Country:US
Mailing Address - Phone:901-850-1150
Mailing Address - Fax:901-850-1102
Practice Address - Street 1:472 W POPLAR AVE STE 200
Practice Address - Street 2:
Practice Address - City:COLLIERVILLE
Practice Address - State:TN
Practice Address - Zip Code:38017-2780
Practice Address - Country:US
Practice Address - Phone:901-850-1150
Practice Address - Fax:901-850-1102
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-05
Last Update Date:2017-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN17172251X0800X
207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Multi-Specialty
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3711730Medicaid
CK8118OtherRAILROAD MEDICARE
MS03404737Medicaid
TN3711730Medicaid
TN4707900001Medicare NSC