Basic Information
| Provider Information | |||||||||
| NPI: | 1033295886 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MSK GROUP, PC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CROSSTOWN BACK AND PAIN INSTITUTE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6077 PRIMACY PKWY STE 140 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381195742 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9017258347 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1350 CONCOURSE AVE STE 363 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381042023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9012606161 | ||||||||
| FaxNumber: | 9012606162 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2006 | ||||||||
| LastUpdateDate: | 08/30/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JENKINS | ||||||||
| AuthorizedOfficialFirstName: | KIM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CO-CEO | ||||||||
| AuthorizedOfficialTelephone: | 9016413000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MSK GROUP, PC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | TN | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 208100000X | TN | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 208VP0014X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine | 332B00000X | TN | N | Suppliers | Durable Medical Equipment & Medical Supplies | 261QP3300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Pain |
ID Information
| ID | Type | State | Issuer | Description | 0970 | 01 | TN | LICENSE PAIN MANAGEMENT CLINIC | OTHER |