Healthcare Provider Details

I. General information

NPI: 1033235619
Provider Name (Legal Business Name): RADIOSURGICAL CENTER OF MEMPHIS, L.P.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2007
Last Update Date: 11/22/2021
Certification Date: 11/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1265 UNION AVE
MEMPHIS TN
38104-3415
US

IV. Provider business mailing address

1265 UNION AVE
MEMPHIS TN
38104-3415
US

V. Phone/Fax

Practice location:
  • Phone: 901-726-6444
  • Fax: 901-726-6145
Mailing address:
  • Phone: 901-726-6444
  • Fax: 901-726-6145

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2471R0002X
TaxonomyRadiation Therapy Radiologic Technologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number0000000074
License Number StateTN

VIII. Authorized Official

Name: MR. JOHN WELLHAUSEN
Title or Position: ADMINISTRATOR
Credential:
Phone: 901-726-6444