Healthcare Provider Details

I. General information

NPI: 1750455945
Provider Name (Legal Business Name): MEMPHIS PEDIATRIC GASTROENTEROLOGY & HEPATOLOGY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

806 ESTATE PL
MEMPHIS TN
38120-0600
US

IV. Provider business mailing address

2670 UNION AVENUE EXT SUITE 1220
MEMPHIS TN
38112-4426
US

V. Phone/Fax

Practice location:
  • Phone: 901-287-4017
  • Fax: 901-287-4013
Mailing address:
  • Phone: 901-458-4282
  • Fax: 901-458-8192

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number
License Number State

VIII. Authorized Official

Name: ROBIN L REESE
Title or Position: OFFICE MANAGER
Credential:
Phone: 901-458-4282