1215030796 NPI number — MEMPHIS ORTHOPAEDIC MEDICAL SUPPLIES, LLC

Table of content: (NPI 1356120240)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215030796 NPI number — MEMPHIS ORTHOPAEDIC MEDICAL SUPPLIES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEMPHIS ORTHOPAEDIC MEDICAL SUPPLIES, LLC
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:
6
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:
1215030796
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/11/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2809 KIRBY PARKWAY
Provider Second Line Business Mailing Address:
SUITE 105
Provider Business Mailing Address City Name:
MEMPHIS
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38119-8241
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
901-755-4344
Provider Business Mailing Address Fax Number:
901-755-4099

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
701 EAST REELFOOT AVENUE
Provider Second Line Business Practice Location Address:
SUITE 500
Provider Business Practice Location Address City Name:
UNION CITY
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38261
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-884-0284
Provider Business Practice Location Address Fax Number:
901-884-0281
Provider Enumeration Date:
09/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WALLACE
Authorized Official First Name:
GUY
Authorized Official Middle Name:
FRED
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
901-755-4344

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 335E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1452529 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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