Basic Information
| Provider Information | |||||||||
| NPI: | 1457343485 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MID SOUTH MEDICAL ASSOCIATES | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 341348 | ||||||||
| Address2: | |||||||||
| City: | BARTLETT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381841348 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9012912400 | ||||||||
| FaxNumber: | 9013790771 | ||||||||
| Practice Location | |||||||||
| Address1: | 1265 UNION AVE | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381043415 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9012912400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2005 | ||||||||
| LastUpdateDate: | 08/01/2007 | ||||||||
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| AuthorizedOfficialLastName: | DENDRINOS | ||||||||
| AuthorizedOfficialFirstName: | GEORGE | ||||||||
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| AuthorizedOfficialTitleorPosition: | GENERAL MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9012912427 | ||||||||
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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 | 207RP1001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207RC0000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
No ID Information.