Healthcare Provider Details

I. General information

NPI: 1073539938
Provider Name (Legal Business Name): THE FAMILY PHYSICIAN GROUP PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 11/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7685 WINCHESTER RD STE 101
MEMPHIS TN
38125-2202
US

IV. Provider business mailing address

2859 VAN LEER DR
MEMPHIS TN
38133-4935
US

V. Phone/Fax

Practice location:
  • Phone: 901-260-9300
  • Fax: 901-751-5541
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number3926223
License Number StateTN

VIII. Authorized Official

Name: ANGIE QUALLS
Title or Position: ADMINISTRATOR
Credential:
Phone: 901-751-5514