1437101821 NPI number — WESLEY NEUROLOGY CLINIC PC

Table of content: (NPI 1437101821)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437101821 NPI number — WESLEY NEUROLOGY CLINIC PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WESLEY NEUROLOGY CLINIC PC
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:
1437101821
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/26/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1885
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:
38101-1885
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
901-725-8920
Provider Business Mailing Address Fax Number:
901-725-8936

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1211 UNION AVE
Provider Second Line Business Practice Location Address:
STE 400
Provider Business Practice Location Address City Name:
MEMPHIS
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38104
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-725-8920
Provider Business Practice Location Address Fax Number:
901-725-8936
Provider Enumeration Date:
05/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LUCAS
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
R
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
901-725-8920

Provider Taxonomy Codes

  • Taxonomy code: 2084N0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3703205 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 09013571 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 122543002 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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