Provider Demographics
NPI:1013112119
Name:PATRICK, JOSEPH (MD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:
Last Name:PATRICK
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 1:2595 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-5905
Mailing Address - Country:US
Mailing Address - Phone:901-260-8551
Mailing Address - Fax:901-260-8590
Practice Address - Street 1:2569 DOUGLASS AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38114-2532
Practice Address - Country:US
Practice Address - Phone:901-271-6200
Practice Address - Fax:901-271-6249
Is Sole Proprietor?:No
Enumeration Date:2007-06-19
Last Update Date:2012-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN47085207Q00000X
SCLL29777207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP5425Medicaid
SC297770Medicaid
TN1523531Medicaid
SCRES0001124Medicare PIN
SCRES0001127Medicare PIN
SCAA3148Medicare UPIN
TN1523531Medicaid
SC9337Medicare PIN
SC297770Medicaid