Healthcare Provider Details

I. General information

NPI: 1063636306
Provider Name (Legal Business Name): SYED HASAN RAZA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 03/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

880 MADISON AVE
MEMPHIS TN
38103-3409
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 901-545-6969
  • Fax:
Mailing address:
  • Phone: 901-545-8336
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number4301095652
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number52391
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: