1275551012 NPI number — FAMILY CANCER CENTER, PLLC

Table of content: (NPI 1275551012)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275551012 NPI number — FAMILY CANCER CENTER, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILY CANCER CENTER, 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:
1275551012
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/09/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 5111
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:
38101-5111
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
901-685-5655
Provider Business Mailing Address Fax Number:
901-685-2590

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1936 W. POPLAR AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLLIERVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38017-0605
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-685-5655
Provider Business Practice Location Address Fax Number:
901-685-2590
Provider Enumeration Date:
07/18/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
WALSH
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
K
Authorized Official Title or Position:
MANAGING PHYSICIAN
Authorized Official Telephone Number:
901-685-5655

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RH0003X , with the licence number: MD0000015925 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 135396002 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3723894 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 090015910 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5C634 . This is a "BCBS" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 4035183 . This is a "BCBS" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".