Healthcare Provider Details

I. General information

NPI: 1326004128
Provider Name (Legal Business Name): LOUIS J MAGNOTTI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2006
Last Update Date: 11/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

877 JEFFERSON AVENUE ATTN: PROVIDER ENROLLMENT
MEMPHIS TN
38103
US

IV. Provider business mailing address

66 N PAULINE ST SUITE 206
MEMPHIS TN
38105-5105
US

V. Phone/Fax

Practice location:
  • Phone: 901-545-6286
  • Fax: 901-545-8122
Mailing address:
  • Phone: 901-448-7642
  • Fax: 901-448-8015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number35504
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: