Healthcare Provider Details

I. General information

NPI: 1437565900
Provider Name (Legal Business Name): CORDOVA PAIN SPECIALISTS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2014
Last Update Date: 03/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1540 APPLING CARE LN SUITE 105
CORDOVA TN
38016-4957
US

IV. Provider business mailing address

1540 APPLING CARE LN SUITE 105
CORDOVA TN
38016-4957
US

V. Phone/Fax

Practice location:
  • Phone: 901-444-3950
  • Fax: 901-444-3866
Mailing address:
  • Phone: 901-444-3950
  • Fax: 901-444-3866

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number2168
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number2168
License Number StateTN

VIII. Authorized Official

Name: JOHN WYATT MILES
Title or Position: AUTHORIZED OFFICIAL
Credential: DO
Phone: 901-444-3950