MEDICARE: POPLAR AVENUE CLINIC PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	2085R0204X	Vascular & Interventional Radiology Physician
2	2086S0129X	Vascular Surgery Physician
3	261QF0050X	Non-Surgical Family Planning Clinic/Center
4	261QM1300X	Multi-Specialty Clinic/Center
5	261QM2500X	Medical Specialty Clinic/Center
6	261QP2300X	Primary Care Clinic/Center
7	261QU0200X	Urgent Care Clinic/Center
8	363A00000X	Physician Assistant
9	363AM0700X	Medical Physician Assistant
10	363AS0400X	Surgical Physician Assistant
11	363LW0102X	Women's Health Nurse Practitioner
12	367500000X	Certified Registered Nurse Anesthetist
13	207VX0201X	Gynecologic Oncology Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1124588793
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	POPLAR AVENUE CLINIC PLLC

Provider Business Mailing Address
First Line	:	PO BOX 172344
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38187-2344
Country	:	US
Telephone Number	:	901-870-8840
Fax Number	:	901-552-5891

Provider Business Practice Location Address
First Line	:	6584 POPLAR AVE STE 400
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38138-3687
Country	:	US
Telephone Number	:	901-300-6713
Fax Number	:	901-552-5891

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	HUDA ALAEDDIN
Credential	:
Telephone Number	:	901-870-8840

Provider Enumeration Date	:	03/20/2019
Last Update Date	:	09/06/2022

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