Healthcare Provider Details

I. General information

NPI: 1235350786
Provider Name (Legal Business Name): PEDIATRIC AND ADOLESCENT MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 04/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1102 BROOKFIELD ROAD 2ND FLOOR
MEMPHIS TN
38119
US

IV. Provider business mailing address

1102 BROOKFIELD ROAD 2ND FLOOR
MEMPHIS TN
38119
US

V. Phone/Fax

Practice location:
  • Phone: 901-761-1880
  • Fax: 901-683-2048
Mailing address:
  • Phone: 901-761-1880
  • Fax: 901-683-2048

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: TAMARA P FOLZ
Title or Position: PRESIDENT
Credential: MD
Phone: 901-761-1880