Healthcare Provider Details

I. General information

NPI: 1013974062
Provider Name (Legal Business Name): BENJAMIN R WALLER III MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 07/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51 N DUNLAP ST FL 2
MEMPHIS TN
38105
US

IV. Provider business mailing address

848 ADAMS AVE
MEMPHIS TN
38103-2816
US

V. Phone/Fax

Practice location:
  • Phone: 901-287-7337
  • Fax: 901-287-4646
Mailing address:
  • Phone: 901-287-5594
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number19846
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number19846
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: