Basic Information
| Provider Information | |||||||||
| NPI: | 1275649063 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MID-SOUTH GASTROENTEROLOGY GROUP, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1417 MONROE AVE | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381043634 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9012727200 | ||||||||
| FaxNumber: | 9012605916 | ||||||||
| Practice Location | |||||||||
| Address1: | 1417 MONROE AVE | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381043634 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9012727200 | ||||||||
| FaxNumber: | 9012605916 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2006 | ||||||||
| LastUpdateDate: | 11/19/2008 | ||||||||
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| AuthorizedOfficialLastName: | ECHOLS | ||||||||
| AuthorizedOfficialFirstName: | SEANDRIA | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 9012727200 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 0000000101 | TN | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 3287965 | 05 | TN | MEDICAID |