Healthcare Provider Details

I. General information

NPI: 1649450909
Provider Name (Legal Business Name): MEMPHIS CHILDREN'S CLINIC,PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2007
Last Update Date: 11/05/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9860 GOODMAN RD
OLIVE BRANCH MS
38654-1722
US

IV. Provider business mailing address

1129 HALE RD
MEMPHIS TN
38116-6373
US

V. Phone/Fax

Practice location:
  • Phone: 662-890-0158
  • Fax: 662-890-8615
Mailing address:
  • Phone: 901-396-0390
  • Fax: 901-507-7561

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. CONNIE PURIFOY
Title or Position: ASSIST. OPERATIONS MANAGER
Credential:
Phone: 901-396-0390