Basic Information
| Provider Information | |||||||||
| NPI: | 1801431499 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GERIATRIC AND HOSPICE ASSOCIATES OF THE MID SOUTH PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6799 GREAT OAKS RD STE 250 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381382584 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9012610700 | ||||||||
| FaxNumber: | 9012610701 | ||||||||
| Practice Location | |||||||||
| Address1: | 6025 WALNUT GROVE RD STE 317 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381202131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9018183921 | ||||||||
| FaxNumber: | 9017673056 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2019 | ||||||||
| LastUpdateDate: | 11/15/2019 | ||||||||
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| AuthorizedOfficialLastName: | VILLANUEVA | ||||||||
| AuthorizedOfficialFirstName: | RANDY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9018183921 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207RG0300X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.