Provider Demographics
NPI:1770798332
Name:UNIVERSITY OF TN CYTOGENETICS LAB-MEMPHIS
Entity type:Organization
Organization Name:UNIVERSITY OF TN CYTOGENETICS LAB-MEMPHIS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, CYTOGENETICS LABORATORY
Authorized Official - Prefix:DR
Authorized Official - First Name:AVIRACHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:THARAPEL
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:901-448-6676
Mailing Address - Street 1:711 JEFFERSON AVE
Mailing Address - Street 2:SUITE 523
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38105-5003
Mailing Address - Country:US
Mailing Address - Phone:901-448-6676
Mailing Address - Fax:901-448-4117
Practice Address - Street 1:711 JEFFERSON AVE
Practice Address - Street 2:SUITE 523
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38105-5003
Practice Address - Country:US
Practice Address - Phone:901-448-6676
Practice Address - Fax:901-448-4117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000002103291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3402016Medicaid
TN3402016Medicaid