Healthcare Provider Details

I. General information

NPI: 1902808488
Provider Name (Legal Business Name): MEMPHIS GASTROENTEROLOGY ENDOSCOPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2005
Last Update Date: 03/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8000 WOLF RIVER BLVD SUITE 200
GERMANTOWN TN
38138
US

IV. Provider business mailing address

8000 WOLF RIVER BLVD SUITE 200
GERMANTOWN TN
38138-1755
US

V. Phone/Fax

Practice location:
  • Phone: 901-747-3630
  • Fax: 901-747-4039
Mailing address:
  • Phone: 901-747-3630
  • Fax: 901-747-4039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0800X
TaxonomyEndoscopy Clinic/Center
License Number0000000066
License Number StateTN

VIII. Authorized Official

Name: MRS. ANGIE B. WILSON
Title or Position: ADMINISTRATOR
Credential:
Phone: 901-747-3630