Basic Information
| Provider Information | |||||||||
| NPI: | 1174842181 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SPECIALTY PHYSICIAN GROUP LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1211 UNION AVE | ||||||||
| Address2: | SUITE 700 | ||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381046638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9015160520 | ||||||||
| FaxNumber: | 9015160528 | ||||||||
| Practice Location | |||||||||
| Address1: | 7460 WOLF RIVER BLVD | ||||||||
| Address2: | |||||||||
| City: | GERMANTOWN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381381760 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9017630200 | ||||||||
| FaxNumber: | 9012601713 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2010 | ||||||||
| LastUpdateDate: | 11/21/2011 | ||||||||
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| AuthorizedOfficialLastName: | MCLEAN | ||||||||
| AuthorizedOfficialFirstName: | CHRISTOPHER | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO/SENIOR VICE PRESIDENT FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 9015160753 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Clinical Cardiac Electrophysiology | 2080P0202X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Cardiology | 208G00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | 363LF0000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363AS0400X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 207RC0000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 1519260 | 05 | TN | MEDICAID | 183763002 | 05 | AR | MEDICAID | 01327007 | 05 | MS | MEDICAID | 4269952 | 01 | TN | BCBS TN | OTHER |