1558393769 NPI number — MR. ROMMEL GABRIEL CHILDRESS MD

Table of content: MR. ROMMEL GABRIEL CHILDRESS MD (NPI 1558393769)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558393769 NPI number — MR. ROMMEL GABRIEL CHILDRESS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHILDRESS
Provider First Name:
ROMMEL
Provider Middle Name:
GABRIEL
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:
1558393769
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1444 E SHELBY DR
Provider Second Line Business Mailing Address:
STE 203
Provider Business Mailing Address City Name:
MEMPHIS
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38116-7239
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
901-345-2833
Provider Business Mailing Address Fax Number:
901-345-2837

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1444 E SHELBY DR
Provider Second Line Business Practice Location Address:
STE 203
Provider Business Practice Location Address City Name:
MEMPHIS
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38116-7239
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-345-2833
Provider Business Practice Location Address Fax Number:
901-345-2837
Provider Enumeration Date:
07/07/2006

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: 207X00000X , with the licence number:  MD12060 , 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)





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