=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407382492
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EGUOSA LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/11/2017
-----------------------------------------------------
Last Update Date | 09/06/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1300 WESLEY DR
-----------------------------------------------------
City | MEMPHIS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38116-6426
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-516-3700
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1891
-----------------------------------------------------
City | COLLIERVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38027-1891
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-516-3700
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | EGUNMWENDIA OGBEIDE
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 901-377-7308
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RX0202X
-----------------------------------------------------
Taxonomy Name | Medical Oncology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------