Provider Demographics
NPI:1720173859
Name:MID SOUTH NEUROLOGY CLINIC PLLC
Entity Type:Organization
Organization Name:MID SOUTH NEUROLOGY CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:MAROUN
Authorized Official - Middle Name:T
Authorized Official - Last Name:DICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:901-531-7007
Mailing Address - Street 1:8584 CORDES CIRCLE
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38139
Mailing Address - Country:US
Mailing Address - Phone:901-531-7007
Mailing Address - Fax:901-531-7008
Practice Address - Street 1:8584 CORDES CIRCLE
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38139
Practice Address - Country:US
Practice Address - Phone:901-531-7007
Practice Address - Fax:901-531-7008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
3729834Medicare ID - Type Unspecified