Healthcare Provider Details

I. General information

NPI: 1346649894
Provider Name (Legal Business Name): KIDS CARE MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2014
Last Update Date: 08/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6073 MT MORIAH RD EXT SUITE 2
MEMPHIS TN
38115-2666
US

IV. Provider business mailing address

6073 MT MORIAH RD EXT SUITE 2
MEMPHIS TN
38115-2666
US

V. Phone/Fax

Practice location:
  • Phone: 901-365-2555
  • Fax: 901-365-2544
Mailing address:
  • Phone: 901-365-2555
  • Fax: 901-365-2544

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number21143
License Number StateTN

VIII. Authorized Official

Name: DR. JAMES LANGSTON COWAN III
Title or Position: OWNER
Credential: MD
Phone: 901-365-2555