Provider Demographics
NPI:1245266733
Name:MID-SOUTH INFECTIOUS DISEASE ASSOCIATES, PLLC
Entity type:Organization
Organization Name:MID-SOUTH INFECTIOUS DISEASE ASSOCIATES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MANOJ
Authorized Official - Middle Name:K
Authorized Official - Last Name:JAIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:901-681-0778
Mailing Address - Street 1:6029 WALNUT GROVE RD STE 209
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-2112
Mailing Address - Country:US
Mailing Address - Phone:901-681-0778
Mailing Address - Fax:901-821-9987
Practice Address - Street 1:6029 WALNUT GROVE RD STE 209
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-2112
Practice Address - Country:US
Practice Address - Phone:901-681-0778
Practice Address - Fax:901-821-9987
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-25
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000026445207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3723463Medicaid
MS009015743Medicaid
TN3723463Medicare ID - Type UnspecifiedMEDICARE
MSC03033Medicare ID - Type Unspecified