Healthcare Provider Details

I. General information

NPI: 1235875576
Provider Name (Legal Business Name): PREMIER PEDIATRICS OF MEMPHIS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2022
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9160 HWY 64 STE 5
LAKELAND TN
38002
US

IV. Provider business mailing address

PO BOX 248
CORDOVA TN
38088-0248
US

V. Phone/Fax

Practice location:
  • Phone: 901-259-9200
  • Fax: 888-494-2188
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. ANGELA MARIE BLACK
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 901-259-9200