=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063873909
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MEMPHIS CARDIOVASCULAR CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/18/2016
-----------------------------------------------------
Last Update Date | 03/18/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6799 GREAT OAKS RD SUITE 100
-----------------------------------------------------
City | MEMPHIS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38138-2588
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-751-0405
-----------------------------------------------------
Fax | 901-751-9694
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6799 GREAT OAKS RD SUITE 100
-----------------------------------------------------
City | MEMPHIS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38138-2588
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-751-0405
-----------------------------------------------------
Fax | 901-751-9694
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | NURSE PRACTITIONER
-----------------------------------------------------
Name | SARA ELIZABETH WILES
-----------------------------------------------------
Credential | FNP-C
-----------------------------------------------------
Telephone | 901-751-0405
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RC0000X
-----------------------------------------------------
Taxonomy Name | Cardiovascular Disease Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------