Basic Information
| Provider Information | |||||||||
| NPI: | 1285042028 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UT REGIONAL ONE PHYSICIANS INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 877 JEFFERSON AVE | ||||||||
| Address2: | ATTN: PROVIDER ENROLLMENT | ||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381032807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9015458336 | ||||||||
| FaxNumber: | 9015458122 | ||||||||
| Practice Location | |||||||||
| Address1: | 877 JEFFERSON AVE | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381032807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9015458336 | ||||||||
| FaxNumber: | 9015458122 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2014 | ||||||||
| LastUpdateDate: | 10/30/2017 | ||||||||
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| AuthorizedOfficialLastName: | SITES | ||||||||
| AuthorizedOfficialFirstName: | RANDOLPH | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9015457125 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | III | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 367500000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 207L00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.