Provider Demographics
NPI:1932258787
Name:MID SOUTH WELLNESS CENTER, INC
Entity Type:Organization
Organization Name:MID SOUTH WELLNESS CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:FLOYD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:901-873-2555
Mailing Address - Street 1:7662 HIGHWAY 51NORTH
Mailing Address - Street 2:SUITE 2
Mailing Address - City:MILLINGTON
Mailing Address - State:TN
Mailing Address - Zip Code:38053
Mailing Address - Country:US
Mailing Address - Phone:901-873-2555
Mailing Address - Fax:901-873-2561
Practice Address - Street 1:7662 HIGHWAY 51NORTH
Practice Address - Street 2:SUITE 2
Practice Address - City:MILLINGTON
Practice Address - State:TN
Practice Address - Zip Code:38053
Practice Address - Country:US
Practice Address - Phone:901-873-2555
Practice Address - Fax:901-873-2561
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-10
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000028821207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3378384Medicaid
TN3378384Medicaid
TNG53357Medicare UPIN