Healthcare Provider Details

I. General information

NPI: 1407078710
Provider Name (Legal Business Name): AUTUMN JOI GOODWIN-SAMSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 01/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

853 JEFFERSON AVE SUITE 201
MEMPHIS TN
38103-2807
US

IV. Provider business mailing address

9034 HOLLYBROOK LANE S
GERMANTOWN TN
38138
US

V. Phone/Fax

Practice location:
  • Phone: 901-448-4750
  • Fax:
Mailing address:
  • Phone: 713-419-9393
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number390200000X
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: