Healthcare Provider Details

I. General information

NPI: 1699185702
Provider Name (Legal Business Name): MICHAEL A WOMACK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2014
Last Update Date: 07/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1265 UNION AVE
MEMPHIS TN
38104
US

IV. Provider business mailing address

PO BOX 1000 DEPT 351
MEMPHIS TN
38148-0001
US

V. Phone/Fax

Practice location:
  • Phone: 901-516-2362
  • Fax: 901-516-8254
Mailing address:
  • Phone: 901-516-2362
  • Fax: 901-516-8254

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number56021
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number56021
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number56021
License Number StateTN
# 4
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number56021
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: