Healthcare Provider Details

I. General information

NPI: 1073514055
Provider Name (Legal Business Name): MEMPHIS AND SHELBY COUNTY HEALTH DEPT.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2005
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1064 BREEDLOVE ST
MEMPHIS TN
38107-2805
US

IV. Provider business mailing address

877 JEFFERSON AVE 5TH FLOOR ADAMS PAVILION
MEMPHIS TN
38103-2807
US

V. Phone/Fax

Practice location:
  • Phone: 901-515-5400
  • Fax: 901-526-1208
Mailing address:
  • Phone: 901-272-0387
  • Fax: 901-272-0292

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number26170
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number20023
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number36735
License Number StateTN

VIII. Authorized Official

Name: MR. CLAYTON MOORE
Title or Position: CONTROLLER
Credential:
Phone: 901-272-0387