Basic Information
| Provider Information | |||||||||
| NPI: | 1992702922 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GERIATRIC GROUP OF MEMPHIS,PLLC | ||||||||
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| OtherOrganizationName: | GERIATRIC GROUP OF MEMPHIS, PLLC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2714 UNION AVENUE EXT | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381124436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9017250872 | ||||||||
| FaxNumber: | 9012786934 | ||||||||
| Practice Location | |||||||||
| Address1: | 2714 UNION AVENUE EXT | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381124436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9017250872 | ||||||||
| FaxNumber: | 9012786934 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2005 | ||||||||
| LastUpdateDate: | 04/07/2016 | ||||||||
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| AuthorizedOfficialLastName: | MCCALLA | ||||||||
| AuthorizedOfficialFirstName: | JENNY WREN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OPERATIONS MGR | ||||||||
| AuthorizedOfficialTelephone: | 9017250872 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0300X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3726736 | 05 | TN | MEDICAID |