=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427067941
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIDSOUTH PRIMARY CARE PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/05/2006
-----------------------------------------------------
Last Update Date | 08/07/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6019 WALNUT GROVE RD
-----------------------------------------------------
City | MEMPHIS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38120-2113
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-240-8294
-----------------------------------------------------
Fax | 901-751-7054
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 84 HAWK GLADE CV
-----------------------------------------------------
City | CORDOVA
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38018-7763
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-240-8294
-----------------------------------------------------
Fax | 901-751-7054
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | DR. ALKA KAMO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 901-240-8294
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | TN0000030512
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------