Basic Information
| Provider Information | |||||||||
| NPI: | 1437105277 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTHEASTERN EMERGENCY PHYSICIANS OF MEMPHIS LLC | ||||||||
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| OtherOrganizationName: | S E EMERGENCY PHYS MEMPHIS | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 633819 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452633819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8882031274 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1 MEMORIAL DR | ||||||||
| Address2: | |||||||||
| City: | ALTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620026722 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184637474 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2006 | ||||||||
| LastUpdateDate: | 09/29/2020 | ||||||||
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| AuthorizedOfficialLastName: | CORVINI | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8652935205 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 09/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PP0204X | TN | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | Pediatric Emergency Medicine | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207P00000X | TN | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200924580A | 05 | IN | MEDICAID | 507218402 | 05 | MO | MEDICAID | 65919342 | 05 | KY | MEDICAID | 158441002 | 05 | AR | MEDICAID | 200533140A | 05 | KS | MEDICAID | 3728394 | 05 | TN | MEDICAID | 529932817 | 05 | AL | MEDICAID | 65909962 | 05 | KY | MEDICAID |