Provider Demographics
NPI:1487797536
Name:MEMPHIS & SHELBY COUNTY PEDIATRIC GROUP
Entity type:Organization
Organization Name:MEMPHIS & SHELBY COUNTY PEDIATRIC GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:
Authorized Official - Last Name:CARTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-396-8366
Mailing Address - Street 1:1444 E SHELBY DR
Mailing Address - Street 2:SUITE 317
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38116-7260
Mailing Address - Country:US
Mailing Address - Phone:901-396-8281
Mailing Address - Fax:
Practice Address - Street 1:6479 WINCHESTER RD
Practice Address - Street 2:SUITE 118
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38115-4240
Practice Address - Country:US
Practice Address - Phone:901-866-2133
Practice Address - Fax:901-866-2136
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN117847OtherUNISON
TN5598466OtherAETNA