Healthcare Provider Details

I. General information

NPI: 1962666420
Provider Name (Legal Business Name): CORY ROBERT EVANS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2008
Last Update Date: 04/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

877 JEFFERSON AVE
MEMPHIS TN
38103-2807
US

IV. Provider business mailing address

910 MADISON AVE 2ND FLOOR
MEMPHIS TN
38103-3403
US

V. Phone/Fax

Practice location:
  • Phone: 901-545-7100
  • Fax:
Mailing address:
  • Phone: 901-448-8140
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD000051039
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number51039
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: