=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285711614
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MED-NET HEALTHCARE AFFILIATES, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/01/2006
-----------------------------------------------------
Last Update Date | 03/27/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 361 N 3RD ST
-----------------------------------------------------
City | MEMPHIS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38105-2710
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-526-7695
-----------------------------------------------------
Fax | 901-525-4483
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 361 N 3RD ST
-----------------------------------------------------
City | MEMPHIS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38105-2710
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-526-7695
-----------------------------------------------------
Fax | 901-525-4483
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT, MEDICAL DIRECTOR
-----------------------------------------------------
Name | MAX FONER
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 901-526-7695
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------