=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063764595
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIDSOUTH INTENAL MEDICINE ASSOCIATES, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/08/2012
-----------------------------------------------------
Last Update Date | 10/08/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 208 IVY BROOK LN
-----------------------------------------------------
City | COLLIERVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38017-8791
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-692-0956
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 208 IVY BROOK LN
-----------------------------------------------------
City | COLLIERVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38017-8791
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-692-0956
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. KAZI ZAMAN
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 901-692-0956
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 41887
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------