1356333561 NPI number — MR. RICKEY R CARSON MD

Table of content: MR. RICKEY R CARSON MD (NPI 1356333561)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356333561 NPI number — MR. RICKEY R CARSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CARSON
Provider First Name:
RICKEY
Provider Middle Name:
R
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1356333561
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/17/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3030 COVINGTON PIKE
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
MEMPHIS
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38128-5049
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
901-800-2152
Provider Business Mailing Address Fax Number:
901-384-6309

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3030 COVINGTON PIKE
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
MEMPHIS
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38128-5049
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-800-2152
Provider Business Practice Location Address Fax Number:
901-384-6309
Provider Enumeration Date:
08/16/2005

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: 207Q00000X , with the licence number:  MD013931 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 13931 , 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: 3882423 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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