=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306886825
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KENNETH I ATAGA MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/07/2006
-----------------------------------------------------
Last Update Date | 11/07/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1325 EASTMORELAND AVE STE 101
-----------------------------------------------------
City | MEMPHIS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-516-8785
-----------------------------------------------------
Fax | 901-516-8358
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1325 EASTMORELAND AVE STE 101
-----------------------------------------------------
City | MEMPHIS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38104-3507
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-516-8785
-----------------------------------------------------
Fax | 901-516-8358
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RH0003X
-----------------------------------------------------
Taxonomy Name | Hematology & Oncology Physician
-----------------------------------------------------
License Number | 9700849
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RH0003X
-----------------------------------------------------
Taxonomy Name | Hematology & Oncology Physician
-----------------------------------------------------
License Number | 57803
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------