Basic Information
| Provider Information | |||||||||
| NPI: | 1710028493 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRIMUS MEDICAL GROUP PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1264 WESLEY DR | ||||||||
| Address2: | #206 | ||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381166400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9013646566 | ||||||||
| FaxNumber: | 9018441439 | ||||||||
| Practice Location | |||||||||
| Address1: | 1264 WESLEY DR | ||||||||
| Address2: | #206 | ||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381166400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9013646566 | ||||||||
| FaxNumber: | 9018441439 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2007 | ||||||||
| LastUpdateDate: | 07/07/2010 | ||||||||
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| AuthorizedOfficialLastName: | EVANS | ||||||||
| AuthorizedOfficialFirstName: | BENJAMINE | ||||||||
| AuthorizedOfficialMiddleName: | F. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9013466566 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD019874 | TN | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 99977 | 01 | TN | BCBS OF TN | OTHER |