MEDICARE: SENTINEL NEUROLOGICAL SERVICES

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084N0400X	Neurology Physician	MD0000039381	TN

General Provider Information

NPI Number	:	1346286853
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SENTINEL NEUROLOGICAL SERVICES

Provider Business Mailing Address
First Line	:	2693 UNION AVENUE EXT
Second Line	:	#204
City	:	MEMPHIS
State	:	TN
Zip	:	38112-4403
Country	:	US
Telephone Number	:	901-454-0152
Fax Number	:	901-454-0154

Provider Business Practice Location Address
First Line	:	2693 UNION AVENUE EXT
Second Line	:	#204
City	:	MEMPHIS
State	:	TN
Zip	:	38112-4403
Country	:	US
Telephone Number	:	901-454-0152
Fax Number	:	901-454-0154

Authorized Official
Title or Position	:	CEO
Name	:	DR. LATAI EBRETTE GRANT BROWN
Credential	:	MD
Telephone Number	:	901-454-0152

Provider Enumeration Date	:	06/22/2006
Last Update Date	:	09/14/2009

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