1104922392 NPI number — WOMENS DIAGNOSTIC GROUP PLLC

Table of content: (NPI 1104922392)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104922392 NPI number — WOMENS DIAGNOSTIC GROUP PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WOMENS DIAGNOSTIC GROUP PLLC
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:
1104922392
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/07/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1000
Provider Second Line Business Mailing Address:
DEPT 34 WOMENS DIAGNOSTIC GROUP PLLC
Provider Business Mailing Address City Name:
MEMPHIS
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38120
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
901-383-1194
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
50 HUMPHREYS CENTER
Provider Second Line Business Practice Location Address:
SUITE 23
Provider Business Practice Location Address City Name:
MEMPHIS
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38120-2373
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-383-1194
Provider Business Practice Location Address Fax Number:
901-383-8985
Provider Enumeration Date:
09/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GAYDEN
Authorized Official First Name:
EVELYN
Authorized Official Middle Name:
W.
Authorized Official Title or Position:
CHIEF MANAGER
Authorized Official Telephone Number:
901-226-0811

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 04483898 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 05675086 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4053282 . This is a "BCBS" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 3377147 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 07421890 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8P034 . This is a "BCBS" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".




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