Basic Information
| Provider Information | |||||||||
| NPI: | 1144392127 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UROLOGY OF MEMPHIS, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1000 | ||||||||
| Address2: | DEPT. 221 | ||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381480001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9018210338 | ||||||||
| FaxNumber: | 9018210384 | ||||||||
| Practice Location | |||||||||
| Address1: | 2996 KATE BOND | ||||||||
| Address2: | SUITE 307 | ||||||||
| City: | BARTLETT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 38133 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9013738333 | ||||||||
| FaxNumber: | 9013739420 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2006 | ||||||||
| LastUpdateDate: | 01/27/2012 | ||||||||
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| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | RICKY | ||||||||
| AuthorizedOfficialMiddleName: | ALLEN | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9013738333 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Other Service Providers | Specialist | 174400000X | MD15982 | TN | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 1521990 | 05 | TN | MEDICAID |