Basic Information
| Provider Information | |||||||||
| NPI: | 1831355064 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POTTER | ||||||||
| FirstName: | THI | ||||||||
| MiddleName: | KIM | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DO | ||||||||
| OtherFirstName: | KIM | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4095 AMERICAN WAY | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381188339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9012719500 | ||||||||
| FaxNumber: | 9012719501 | ||||||||
| Practice Location | |||||||||
| Address1: | 4095 AMERICAN WAY | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381188339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9012719500 | ||||||||
| FaxNumber: | 9012719501 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2008 | ||||||||
| LastUpdateDate: | 11/14/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD0000046257 | TN | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207P00000X | 46257 | TN | N | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1518265 | 05 | TN | MEDICAID |