Provider Demographics
NPI:1649450909
Name:MEMPHIS CHILDREN'S CLINIC,PLLC
Entity type:Organization
Organization Name:MEMPHIS CHILDREN'S CLINIC,PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSIST. OPERATIONS MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:PURIFOY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-396-0390
Mailing Address - Street 1:1129 HALE RD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38116-6373
Mailing Address - Country:US
Mailing Address - Phone:901-396-0390
Mailing Address - Fax:901-507-7561
Practice Address - Street 1:9860 GOODMAN RD
Practice Address - Street 2:
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654-1722
Practice Address - Country:US
Practice Address - Phone:662-890-0158
Practice Address - Fax:662-890-8615
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEMPHIS CHILDREN'S CLINIC, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-11-05
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3382354Medicaid