Healthcare Provider Details

I. General information

NPI: 1346219342
Provider Name (Legal Business Name): MID-SOUTH NEPHROLOGY CONSULTANTS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 02/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6490 MOUNT MORIAH ROAD EXT STE 200
MEMPHIS TN
38115-3841
US

IV. Provider business mailing address

6490 MOUNT MORIAH ROAD EXT STE 200
MEMPHIS TN
38115-3841
US

V. Phone/Fax

Practice location:
  • Phone: 901-565-0244
  • Fax: 901-565-0616
Mailing address:
  • Phone: 901-565-0244
  • Fax: 901-565-0616

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier208992305
Identifier TypeMEDICAID
Identifier StateMO
Identifier Issuer
# 2
Identifier3373435
Identifier TypeMEDICAID
Identifier StateTN
Identifier Issuer
# 3
Identifier5B527
Identifier TypeOTHER
Identifier StateAR
Identifier IssuerBLUE CROSS BLUE SHIELD
# 4
Identifier152287002
Identifier TypeMEDICAID
Identifier StateAR
Identifier Issuer
# 5
Identifier4030327
Identifier TypeOTHER
Identifier StateTN
Identifier IssuerBLUE CROSS BLUE SHIELD
# 6
Identifier09983030
Identifier TypeMEDICAID
Identifier StateMS
Identifier Issuer

VIII. Authorized Official

Name: DOMINGA HERNANDEZ
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 901-565-0244