Basic Information
| Provider Information | |||||||||
| NPI: | 1831249341 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ENDOSCOPY CENTER OF THE MID-SOUTH, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3960 KNIGHT ARNOLD RD | ||||||||
| Address2: | SUITE 117 | ||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381183035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9013698509 | ||||||||
| FaxNumber: | 9013698466 | ||||||||
| Practice Location | |||||||||
| Address1: | 3960 KNIGHT ARNOLD RD | ||||||||
| Address2: | SUITE 117 | ||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381183035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9013698509 | ||||||||
| FaxNumber: | 9013698466 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2007 | ||||||||
| LastUpdateDate: | 09/18/2007 | ||||||||
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| AuthorizedOfficialLastName: | KHAN | ||||||||
| AuthorizedOfficialFirstName: | TARIQ | ||||||||
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| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 9013698509 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0800X | Y | Ambulatory Health Care Facilities | Clinic/Center | Endoscopy |
ID Information
| ID | Type | State | Issuer | Description | 3288955 | 05 | TN | MEDICAID |