1770266785 NPI number — OLIVIA SANDERSON GREGORY DPT

Table of content: OLIVIA SANDERSON GREGORY DPT (NPI 1770266785)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770266785 NPI number — OLIVIA SANDERSON GREGORY DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GREGORY
Provider First Name:
OLIVIA
Provider Middle Name:
SANDERSON
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPT
Provider Gender Code:
F

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:
1770266785
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/12/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6325 HUMPHREYS BLVD
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:
38120-2300
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
901-522-7700
Provider Business Mailing Address Fax Number:
901-522-2600

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
391 SOUTHCREST CIR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTHAVEN
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38671-6730
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
91-522-7700
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/08/2023

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: 225100000X , with the licence number:  15300 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: PT7612 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 200006016 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: Q088576 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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