Basic Information
| Provider Information | |||||||||
| NPI: | 1518192855 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ADDISON | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | HYUN MCGUIRE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MCGUIRE | ||||||||
| OtherFirstName: | ELIZABETH | ||||||||
| OtherMiddleName: | HYUN | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2670 MCINGVALE RD STE J | ||||||||
| Address2: | |||||||||
| City: | HERNANDO | ||||||||
| State: | MS | ||||||||
| PostalCode: | 386328696 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9016413000 | ||||||||
| FaxNumber: | 9017012428 | ||||||||
| Practice Location | |||||||||
| Address1: | 8040 WOLF RIVER BLVD | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | GERMANTOWN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381381773 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9015226440 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2009 | ||||||||
| LastUpdateDate: | 05/26/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 8324 | TN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | PT5199 | MS | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.