Healthcare Provider Details

I. General information

NPI: 1003855420
Provider Name (Legal Business Name): COLLIERVILLE ORTHOPEDICS AND
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2006
Last Update Date: 11/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

472 W POPLAR AVE STE 200
COLLIERVILLE TN
38017-2780
US

IV. Provider business mailing address

PO BOX 9616
BELFAST ME
04915-9616
US

V. Phone/Fax

Practice location:
  • Phone: 901-850-1150
  • Fax: 901-850-1102
Mailing address:
  • Phone: 901-850-1150
  • Fax: 901-850-1102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number1717
License Number StateTN

VIII. Authorized Official

Name: DEDE COKE
Title or Position: OFFICE MANAGER
Credential:
Phone: 901-850-1150