Basic Information
| Provider Information | |||||||||
| NPI: | 1104237007 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WHITE | ||||||||
| FirstName: | JEREMY | ||||||||
| MiddleName: | SHANE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 965 RIDGE LAKE BLVD STE 315 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381209401 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 501 MARSHALL ST STE 104 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392021663 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019696404 | ||||||||
| FaxNumber: | 6019734541 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2014 | ||||||||
| LastUpdateDate: | 05/27/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0011X | A169147 | CA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 207RI0011X | 29993 | MS | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
No ID Information.