Healthcare Provider Details

I. General information

NPI: 1417442757
Provider Name (Legal Business Name): ALLERGY ASTHMA IMMUNOLOGY CENTER, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2018
Last Update Date: 06/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6401 POPLAR AVE STE 300
MEMPHIS TN
38119-4810
US

IV. Provider business mailing address

6139 CHAPELLE CIR W
MEMPHIS TN
38120-4062
US

V. Phone/Fax

Practice location:
  • Phone: 901-757-6100
  • Fax: 901-757-6109
Mailing address:
  • Phone: 901-757-6100
  • Fax: 901-757-6109

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. MELANIE A BLACK
Title or Position: ADMINISTRATOR
Credential:
Phone: 901-757-6100