Basic Information
| Provider Information | |||||||||
| NPI: | 1114920246 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JAMESON | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | DEAN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 6077 PRIMACY PKWY STE 140 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381195742 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9017258347 | ||||||||
| FaxNumber: | 9012597637 | ||||||||
| Practice Location | |||||||||
| Address1: | 6286 BRIARCREST AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381204023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9016413000 | ||||||||
| FaxNumber: | 9017012400 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2005 | ||||||||
| LastUpdateDate: | 03/17/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 20296 | TN | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XX0004X | 20296 | TN | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Foot and Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 3051593 | 05 | TN | MEDICAID | 620819926 | 01 | TN | AETNA | OTHER | 007238527 | 05 | MS | MEDICAID | 3037120 | 01 | TN | BCBS | OTHER | 2675407 | 01 | TN | CIGNA | OTHER | 620819926 | 01 | TN | TRICARE | OTHER | 110318002 | 05 | AR | MEDICAID | 4110755 | 01 | TN | AETNA | OTHER | 117286001 | 05 | AR | MEDICAID | 3371161 | 05 | TN | MEDICAID | 200022156 | 01 | TN | RAILROAD MEDICARE | OTHER | 00000001062 | 01 | TN | TLC | OTHER | 620819926 | 01 | MS | BCBS | OTHER | 620819926 | 01 | TN | CIGNA | OTHER | 7187860 | 05 | MS | MEDICAID |