Healthcare Provider Details

I. General information

NPI: 1104802875
Provider Name (Legal Business Name): MARK RICHARD GYENES HS(IDC/DMT)
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/15/2005
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 AUCTION AVE
MEMPHIS TN
38105-1502
US

IV. Provider business mailing address

2 AUCTION AVE
MEMPHIS TN
38105-1502
US

V. Phone/Fax

Practice location:
  • Phone: 901-544-3912
  • Fax: 901-544-3915
Mailing address:
  • Phone: 901-544-3912
  • Fax: 901-544-3915

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code146N00000X
TaxonomyBasic Emergency Medical Technician
License NumberB1583538
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1710I1003X
TaxonomyIndependent Duty Medical Technicians
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code247000000X
TaxonomyHealth Information Technician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License NumberA00065327
License Number StateMD
# 7
Primary TaxonomyN
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number3900062
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: