1326218868 NPI number — PEDIATRIC UROLOGY ASSOCIATES OF THE MID-SOUTH, P.C.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326218868 NPI number — PEDIATRIC UROLOGY ASSOCIATES OF THE MID-SOUTH, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEDIATRIC UROLOGY ASSOCIATES OF THE MID-SOUTH, P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1326218868
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/25/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1920 KIRBY PKWY
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
GERMANTOWN
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38138-3696
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
901-751-0500
Provider Business Mailing Address Fax Number:
901-751-0551

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1920 KIRBY PKWY
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
GERMANTOWN
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38138-3696
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-751-0500
Provider Business Practice Location Address Fax Number:
901-751-0551
Provider Enumeration Date:
03/11/2008

Additional Information

Authorized Official

Authorized Official Last Name:
JERKINS
Authorized Official First Name:
GERALD
Authorized Official Middle Name:
R
Authorized Official Title or Position:
PEDIATRIC UROLOGIST
Authorized Official Telephone Number:
901-751-0500

Provider Taxonomy Codes

  • Taxonomy code: 261QM2500X , with the licence number:  MD0000008476 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3378412 . This is a "MEDICARE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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