Provider Demographics
NPI:1184788762
Name:TRI-STATE NEUROLOGY PLLC
Entity type:Organization
Organization Name:TRI-STATE NEUROLOGY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT / OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:J
Authorized Official - Last Name:WANG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-820-0141
Mailing Address - Street 1:5100 SANDERLIN AVE STE 2100
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38117-4387
Mailing Address - Country:US
Mailing Address - Phone:901-820-0141
Mailing Address - Fax:901-820-0144
Practice Address - Street 1:5100 SANDERLIN AVE STE 2100
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38117-4387
Practice Address - Country:US
Practice Address - Phone:901-820-0141
Practice Address - Fax:901-820-0144
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-20
Last Update Date:2017-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD00000308782084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR138488001Medicaid
MO206187502Medicaid
MS00126261Medicaid
TN3838091Medicaid
MS00126261Medicaid
MO206187502Medicaid