Healthcare Provider Details

I. General information

NPI: 1740558147
Provider Name (Legal Business Name): SPECIALTY ORTHOPEDICS P C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2011
Last Update Date: 12/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5210 POPLAR AVE SUITE 200
MEMPHIS TN
38119-3515
US

IV. Provider business mailing address

5210 POPLAR AVE SUITE 200
MEMPHIS TN
38119-3515
US

V. Phone/Fax

Practice location:
  • Phone: 901-682-9161
  • Fax: 901-767-9584
Mailing address:
  • Phone: 901-682-9161
  • Fax: 901-767-9584

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number7341
License Number StateTN

VIII. Authorized Official

Name: DR. RICHARD L ENNIS
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 901-682-9161