Healthcare Provider Details

I. General information

NPI: 1043260763
Provider Name (Legal Business Name): MID-SOUTH IMAGING & THERAPEUTICS, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 10/16/2024
Certification Date: 10/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7600 WOLF RIVER BLVD. #200
GERMANTOWN TN
38138
US

IV. Provider business mailing address

PO BOX 5083
MEMPHIS TN
38101-5083
US

V. Phone/Fax

Practice location:
  • Phone: 901-747-1000
  • Fax: 901-747-1001
Mailing address:
  • Phone: 901-383-8860
  • Fax: 901-383-8985

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: DR. JOHN A ELLZEY
Title or Position: PRESIDENT
Credential: MD
Phone: 901-473-6406