Healthcare Provider Details

I. General information

NPI: 1417932492
Provider Name (Legal Business Name): GASTROENTEROLOGY CENTER OF THE MIDSOUTH PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2005
Last Update Date: 03/10/2025
Certification Date: 03/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

ONE GI CREDENTIALING DEPARTMENT PO BOX 381468
GERMANTOWN TN
38183-1468
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State

VIII. Authorized Official

Name: AIMEE CATHLEEN JUDY
Title or Position: DIRECTOR, CREDENTIALING
Credential:
Phone: 901-737-4665