=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588664726
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GERALD JOHNSON PRESBURY M.D
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/29/2005
-----------------------------------------------------
Last Update Date | 03/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 50 N DUNLAP ST
-----------------------------------------------------
City | MEMPHIS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38103-2800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-869-5708
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 777 WASHINGTON AVE SUITE P 110
-----------------------------------------------------
City | MEMPHIS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38105-4550
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-448-2000
-----------------------------------------------------
Fax | 901-287-6072
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207PP0204X
-----------------------------------------------------
Taxonomy Name | Pediatric Emergency Medicine (Emergency Medicine) Physician
-----------------------------------------------------
License Number | 13054
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | MD 13054
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------