Basic Information
| Provider Information | |||||||||
| NPI: | 1992758882 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THE CONRAD PEARSON CLINIC, PC | ||||||||
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| OtherOrganizationName: | UROLOGY CENTER OF THE SOUTH, PC | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1325 WOLF PARK DR | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | GERMANTOWN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381381742 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9012523411 | ||||||||
| FaxNumber: | 9013846422 | ||||||||
| Practice Location | |||||||||
| Address1: | 1325 WOLF PARK DR | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | GERMANTOWN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381381742 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9012523400 | ||||||||
| FaxNumber: | 9016820047 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2006 | ||||||||
| LastUpdateDate: | 12/03/2020 | ||||||||
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| AuthorizedOfficialLastName: | DEGEORGE | ||||||||
| AuthorizedOfficialFirstName: | RUSSELL | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9012523411 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | N/A FOR THE GROUP | TN | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 163577002 | 05 | AR | MEDICAID | 5F646 | 01 | AR | BLUE CROSS AR | OTHER | 72409 | 01 | FL | BLUE CROSS FL | OTHER | 5608209 | 01 | AETNA | OTHER | 3042605 | 01 | TN | BLUE CROSS TN | OTHER |