Healthcare Provider Details

I. General information

NPI: 1891827390
Provider Name (Legal Business Name): CQRNELL CHARLES FAQUIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2749 HUNTERS DR
GERMANTOWN TN
38138-6224
US

IV. Provider business mailing address

2749 HUNTERS DR
GERMANTOWN TN
38138-6224
US

V. Phone/Fax

Practice location:
  • Phone: 901-755-4387
  • Fax: 901-755-0718
Mailing address:
  • Phone: 901-755-4387
  • Fax: 901-755-0718

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD3354
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: