Provider Demographics
NPI:1265589261
Name:MEDICAL GROUP OF MEMPHIS LLC
Entity type:Organization
Organization Name:MEDICAL GROUP OF MEMPHIS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:
Authorized Official - Last Name:STRUBLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-726-0200
Mailing Address - Street 1:8040 WOLF RIVER BLVD
Mailing Address - Street 2:SUITE #200
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138
Mailing Address - Country:US
Mailing Address - Phone:901-726-0200
Mailing Address - Fax:
Practice Address - Street 1:8040 WOLF RIVER BLVD
Practice Address - Street 2:SUITE #200
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138
Practice Address - Country:US
Practice Address - Phone:901-726-0200
Practice Address - Fax:901-726-0210
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-04
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3373040Medicare ID - Type Unspecified