Basic Information
| Provider Information | |||||||||
| NPI: | 1730380304 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEDBETTER | ||||||||
| FirstName: | CHRISTOPHER | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 877 JEFFERSON AVE | ||||||||
| Address2: | ATTN: PROVIDER ENROLLMENT | ||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381032807 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 6555 QUINCE RD | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381198202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9015155704 | ||||||||
| FaxNumber: | 9015155729 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2007 | ||||||||
| LastUpdateDate: | 01/24/2018 | ||||||||
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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 | 208800000X | 44939 | TN | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 4355605 | 01 | TN | BCBS | OTHER | 07150821 | 05 | MS | MEDICAID | P01288704 | 01 | TN | RAILROAD MEDICARE | OTHER | 177760001 | 05 | AR | MEDICAID | Q002444 | 05 | TN | MEDICAID |