Healthcare Provider Details

I. General information

NPI: 1922092949
Provider Name (Legal Business Name): DOUGLAS MERRITT MACGAW M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2005
Last Update Date: 10/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2860 COVINGTON PIKE
MEMPHIS TN
38128-8090
US

IV. Provider business mailing address

2860 COVINGTON PIKE
MEMPHIS TN
38128-8090
US

V. Phone/Fax

Practice location:
  • Phone: 901-252-6034
  • Fax: 901-252-6048
Mailing address:
  • Phone: 901-252-6034
  • Fax: 901-252-6048

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number07103
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number07103
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: