1598902041 NPI number — MILLIE D SUTHERLAND B.S.

Table of content: MILLIE D SUTHERLAND B.S. (NPI 1598902041)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598902041 NPI number — MILLIE D SUTHERLAND B.S.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SUTHERLAND
Provider First Name:
MILLIE
Provider Middle Name:
D
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
B.S.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GOOSBY
Provider Other First Name:
MILLIE
Provider Other Middle Name:
D
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
B.S.
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1598902041
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/20/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2150 WHITNEY AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MEMPHIS
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38127-6662
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
901-353-5440
Provider Business Mailing Address Fax Number:
901-353-5464

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2150 WHITNEY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MEMPHIS
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38127-6662
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-353-5440
Provider Business Practice Location Address Fax Number:
901-353-5464
Provider Enumeration Date:
01/20/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 104100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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