1336386879 NPI number — MATTHEW PHILIP HOLLIS AUD

Table of content: MATTHEW PHILIP HOLLIS AUD (NPI 1336386879)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336386879 NPI number — MATTHEW PHILIP HOLLIS AUD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HOLLIS
Provider First Name:
MATTHEW
Provider Middle Name:
PHILIP
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
AUD
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:
1336386879
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/17/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
850 POPLAR AVE
Provider Second Line Business Mailing Address:
BLDG 2
Provider Business Mailing Address City Name:
MEMPHIS
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38105-4607
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5625 POPLAR 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:
38119-3816
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-761-1220
Provider Business Practice Location Address Fax Number:
901-763-4332
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: 231H00000X , with the licence number:  1527 , 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: 12147291 . This is a "AMERICAN SPEECH AND HEARING ASSOCIATION" identifier . This identifiers is of the category "OTHER".




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