Basic Information
| Provider Information | |||||||||
| NPI: | 1437101821 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WESLEY NEUROLOGY CLINIC PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1885 | ||||||||
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| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381011885 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9017258920 | ||||||||
| FaxNumber: | 9017258936 | ||||||||
| Practice Location | |||||||||
| Address1: | 1211 UNION AVE | ||||||||
| Address2: | STE 400 | ||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 38104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9017258920 | ||||||||
| FaxNumber: | 9017258936 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2006 | ||||||||
| LastUpdateDate: | 09/26/2008 | ||||||||
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| AuthorizedOfficialLastName: | LUCAS | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 9017258920 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 3703205 | 05 | TN | MEDICAID | 09013571 | 05 | MS | MEDICAID | 122543002 | 05 | AR | MEDICAID |