Healthcare Provider Details

I. General information

NPI: 1285042028
Provider Name (Legal Business Name): UT REGIONAL ONE PHYSICIANS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2014
Last Update Date: 10/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

877 JEFFERSON AVE
MEMPHIS TN
38103-2807
US

IV. Provider business mailing address

877 JEFFERSON AVE ATTN: PROVIDER ENROLLMENT
MEMPHIS TN
38103-2807
US

V. Phone/Fax

Practice location:
  • Phone: 901-545-8336
  • Fax: 901-545-8122
Mailing address:
  • Phone: 901-545-8336
  • Fax: 901-545-8122

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: RANDOLPH SITES III
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 901-545-7125