Healthcare Provider Details

I. General information

NPI: 1548211378
Provider Name (Legal Business Name): INTERVENTIONAL CARDIOLOGY OF THE MIDSOUTH, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2006
Last Update Date: 08/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1211 UNION AVE SUITE 975
MEMPHIS TN
38104-6638
US

IV. Provider business mailing address

MSC 410705 PO BOX 415000
NASHVILLE TN
37241-0001
US

V. Phone/Fax

Practice location:
  • Phone: 901-725-0347
  • Fax: 901-725-5359
Mailing address:
  • Phone: 901-725-0347
  • Fax: 901-725-5359

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License NumberMD0000018928
License Number StateTN

VIII. Authorized Official

Name: GEORGE J SMITH
Title or Position: PRESIDENT
Credential: M.D.
Phone: 901-725-0347