Basic Information
| Provider Information | |||||||||
| NPI: | 1093131401 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MID SOUTH PAIN AND ANESTHESIA CLINIC | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 382067 | ||||||||
| Address2: | |||||||||
| City: | GERMANTOWN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381832067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9018210338 | ||||||||
| FaxNumber: | 9017617738 | ||||||||
| Practice Location | |||||||||
| Address1: | 6005 PARK AVE | ||||||||
| Address2: | SUITE 502 | ||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381195202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9017610800 | ||||||||
| FaxNumber: | 9017617738 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2014 | ||||||||
| LastUpdateDate: | 06/29/2022 | ||||||||
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| AuthorizedOfficialLastName: | GREEN | ||||||||
| AuthorizedOfficialFirstName: | PHILLIP | ||||||||
| AuthorizedOfficialMiddleName: | EDWARD | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9017610800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 06/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | 017865 | TN | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.