Healthcare Provider Details

I. General information

NPI: 1538703038
Provider Name (Legal Business Name): SCOTT ERIC BALOGH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2019
Last Update Date: 10/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65 GERMANTOWN COURT SUITE 203
CORDOVA TN
38018
US

IV. Provider business mailing address

65 GERMANTOWN COURT SUITE 203
CORDOVA TN
38018
US

V. Phone/Fax

Practice location:
  • Phone: 901-305-6789
  • Fax: 901-305-6973
Mailing address:
  • Phone: 901-305-6789
  • Fax: 901-305-6973

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. SCOTT ERIC BALOGH
Title or Position: OWNER
Credential: M.D.
Phone: 901-305-6789