Healthcare Provider Details

I. General information

NPI: 1841566288
Provider Name (Legal Business Name): ERIC E MCCLENDON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2012
Last Update Date: 07/27/2020
Certification Date: 07/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 WILLOWBROOK RD
COLUMBUS MS
39705-2015
US

IV. Provider business mailing address

965 RIDGE LAKE BLVD STE 103
MEMPHIS TN
38120-9446
US

V. Phone/Fax

Practice location:
  • Phone: 662-240-1412
  • Fax: 662-240-1949
Mailing address:
  • Phone:
  • Fax: 901-227-8591

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number23906
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: