Provider Demographics
NPI:1841336583
Name:MID SOUTH PAIN & ANESTHESIA CLINIC INC
Entity type:Organization
Organization Name:MID SOUTH PAIN & ANESTHESIA CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:E
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:901-761-0800
Mailing Address - Street 1:PO BOX 382067
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38183-2067
Mailing Address - Country:US
Mailing Address - Phone:901-761-0800
Mailing Address - Fax:901-761-7738
Practice Address - Street 1:3087 PROFESSIONAL PLZ
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-7912
Practice Address - Country:US
Practice Address - Phone:901-761-0800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000017865174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3722886Medicaid
MS00586809Medicaid