Healthcare Provider Details

I. General information

NPI: 1487796264
Provider Name (Legal Business Name): GERMANTOWN OB-GYN GROUP PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 02/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7516 CAPITAL DR
GERMANTOWN TN
38138-3847
US

IV. Provider business mailing address

7516 CAPITAL DR
GERMANTOWN TN
38138-3847
US

V. Phone/Fax

Practice location:
  • Phone: 901-753-4200
  • Fax: 901-753-4463
Mailing address:
  • Phone: 901-753-4200
  • Fax: 901-753-4463

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number012168
License Number StateTN

VIII. Authorized Official

Name: TANJA LU TODD
Title or Position: OWNER
Credential: MD
Phone: 901-753-4200