1609427939 NPI number — TRI STATE INTERVENTIONAL PAIN CLINIC PLLC

Table of content: (NPI 1609427939)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609427939 NPI number — TRI STATE INTERVENTIONAL PAIN CLINIC PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TRI STATE INTERVENTIONAL PAIN CLINIC 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:
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NPI Number Information

NPI Number:
1609427939
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/27/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3450 LAKE POINTE
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:
38125-8842
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
901-219-6740
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
310 JUDGE SMITH DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARION
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72364-2220
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-603-8555
Provider Business Practice Location Address Fax Number:
901-730-1229
Provider Enumeration Date:
09/27/2019

Additional Information

Authorized Official

Authorized Official Last Name:
MCCOURT
Authorized Official First Name:
CAROL
Authorized Official Middle Name:
J
Authorized Official Title or Position:
SOLE PROPRIETOR
Authorized Official Telephone Number:
901-219-6740

Provider Taxonomy Codes

  • Taxonomy code: 207LP2900X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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