Healthcare Provider Details

I. General information

NPI: 1366509721
Provider Name (Legal Business Name): MEMPHIS PRIMARY CARE & WELLNESS ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2007
Last Update Date: 08/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7645 WOLF RIVER CIR STE 100
GERMANTOWN TN
38138-1751
US

IV. Provider business mailing address

7645 WOLF RIVER CIR STE 100
GERMANTOWN TN
38138-1751
US

V. Phone/Fax

Practice location:
  • Phone: 901-405-0275
  • Fax: 901-405-0288
Mailing address:
  • Phone: 901-405-0275
  • Fax: 901-869-2908

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2084P0005X
TaxonomyNeurodevelopmental Disabilities Physician
License Number
License Number State

VIII. Authorized Official

Name: LORETTA MOSIEJ BROWN
Title or Position: OFFICE ADMINISTRATOR
Credential:
Phone: 901-405-0275