Basic Information
| Provider Information | |||||||||
| NPI: | 1174872295 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UT MEDICAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 179 EASTLAND DR | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381116930 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9017612979 | ||||||||
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| Practice Location | |||||||||
| Address1: | 853 JEFFERSON AVE | ||||||||
| Address2: | ROOM 201 | ||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381032807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9015457366 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/05/2012 | ||||||||
| LastUpdateDate: | 09/05/2012 | ||||||||
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| AuthorizedOfficialLastName: | MUIRHEAD | ||||||||
| AuthorizedOfficialFirstName: | MARILYN | ||||||||
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| AuthorizedOfficialTitleorPosition: | NEONATAL NURSE PRACTITIONER | ||||||||
| AuthorizedOfficialTelephone: | 9015457366 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | NNP-BC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NW0100X | 8199402 | TN | Y | Hospitals | General Acute Care Hospital | Women |
ID Information
| ID | Type | State | Issuer | Description | 8198662 | 01 | TN | ADVANCED PRACTICE LIICENSE | OTHER |