Basic Information
| Provider Information | |||||||||
| NPI: | 1578558698 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MEDSOUTH HEALTHCARE PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1700 WOODLAWN AVE | ||||||||
| Address2: | |||||||||
| City: | DYERSBURG | ||||||||
| State: | TN | ||||||||
| PostalCode: | 380242028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7312874500 | ||||||||
| FaxNumber: | 7312874804 | ||||||||
| Practice Location | |||||||||
| Address1: | 1700 WOODLAWN AVE | ||||||||
| Address2: | |||||||||
| City: | DYERSBURG | ||||||||
| State: | TN | ||||||||
| PostalCode: | 380242028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7312874500 | ||||||||
| FaxNumber: | 7312874804 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | ALRED | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 7312874512 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 208000000X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 207R00000X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207RP1001X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207Q00000X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3705380 | 05 | TN | MEDICAID | 3705385 | 05 | TN | MEDICAID | 3705383 | 05 | TN | MEDICAID | 3705386 | 05 | TN | MEDICAID | 3705388 | 05 | TN | MEDICAID | 3705389 | 05 | TN | MEDICAID |