Healthcare Provider Details

I. General information

NPI: 1902128564
Provider Name (Legal Business Name): OKLAHOMA PHS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/24/2010
Last Update Date: 02/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9155 CRESTWYN HILLS DR
MEMPHIS TN
38125-8501
US

IV. Provider business mailing address

9155 CRESTWYN HILLS DR
MEMPHIS TN
38125-8501
US

V. Phone/Fax

Practice location:
  • Phone: 901-261-4843
  • Fax: 901-261-4849
Mailing address:
  • Phone: 901-261-4843
  • Fax: 901-261-4849

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: TANYA NOAH
Title or Position: REVENUE CYCLE MANAGER
Credential:
Phone: 96012614843