Basic Information
| Provider Information | |||||||||
| NPI: | 1679614861 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DOUGAN | ||||||||
| FirstName: | MAX | ||||||||
| MiddleName: | R. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 154 PERKINS EXTD | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 38117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9017674353 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3000 GETWELL RD | ||||||||
| Address2: | DELTA MEDICAL CENTER | ||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381182205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9013698560 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2007 | ||||||||
| LastUpdateDate: | 05/18/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | E3994 | AR | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | MD013506 | TN | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 208D00000X | MD013506 | TN | N | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 3006364 | 05 | TN | MEDICAID |