Healthcare Provider Details

I. General information

NPI: 1669508305
Provider Name (Legal Business Name): SPECIALTY ORTHOPEDICS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/26/2007
Last Update Date: 03/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5220 PARK AVE SUITE 100
MEMPHIS TN
38119-3540
US

IV. Provider business mailing address

5220 PARK AVE SUITE 100
MEMPHIS TN
38119-3540
US

V. Phone/Fax

Practice location:
  • Phone: 901-682-9161
  • Fax: 901-767-9584
Mailing address:
  • Phone: 901-682-9161
  • Fax: 901-767-9584

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number7341
License Number StateTN

VIII. Authorized Official

Name: DR. RICHARD L ENNIS
Title or Position: PRESIDENT
Credential: MD
Phone: 901-682-9161