Healthcare Provider Details

I. General information

NPI: 1649211418
Provider Name (Legal Business Name): CARDIOVASCULAR SURGERY CLINIC, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date: 02/04/2019
Reactivation Date: 04/24/2019

III. Provider practice location address

6029 WALNUT GROVE RD SUITE 401
MEMPHIS TN
38120-2112
US

IV. Provider business mailing address

6029 WALNUT GROVE RD SUITE 401
MEMPHIS TN
38120-2112
US

V. Phone/Fax

Practice location:
  • Phone: 901-747-3066
  • Fax: 901-747-2966
Mailing address:
  • Phone: 901-747-3066
  • Fax: 901-747-2966

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number17068
License Number StateTN

VIII. Authorized Official

Name: HARVEY EDWARD GARRETT
Title or Position: PRESIDENT
Credential: M.D.
Phone: 901-747-3066