Provider Demographics
NPI:1255602587
Name:SPG II LLC
Entity type:Organization
Organization Name:SPG II LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SVP/CFO
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:R
Authorized Official - Last Name:LANE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-478-0525
Mailing Address - Street 1:1211 UNION AVE
Mailing Address - Street 2:SUITE 700
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-6638
Mailing Address - Country:US
Mailing Address - Phone:901-516-0520
Mailing Address - Fax:901-516-0528
Practice Address - Street 1:1264 WESLEY DR STE 304
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38116-6445
Practice Address - Country:US
Practice Address - Phone:901-398-1990
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-18
Last Update Date:2024-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric CardiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNDT0543OtherRAILROAD MEDICARE
TN1527696Medicaid
TN4321634OtherBCBS
MS02932831Medicaid
AR192594002Medicaid
MS02932831Medicaid
TN4321634OtherBCBS