Provider Demographics
NPI:1831166677
Name:NORTHCROSS, PHILLIP R (MC)
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:R
Last Name:NORTHCROSS
Suffix:
Gender:M
Credentials:MC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3445 POPLAR AVE
Mailing Address - Street 2:STE 13
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38111-4667
Mailing Address - Country:US
Mailing Address - Phone:901-523-7781
Mailing Address - Fax:
Practice Address - Street 1:3440 POPLAR AVE
Practice Address - Street 2:SUITE 13
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38111-4653
Practice Address - Country:US
Practice Address - Phone:901-523-7781
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-01
Last Update Date:2016-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD017326207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3020931Medicaid
TN3061799OtherBCBST
A98468Medicare UPIN
TN3020931Medicare ID - Type UnspecifiedTN MEDICARE