=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609022839
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHYSICIANS OF HEARTS P.L.L.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/07/2008
-----------------------------------------------------
Last Update Date | 03/04/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6005 PARK AVE STE 702
-----------------------------------------------------
City | MEMPHIS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38119-5217
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-682-7241
-----------------------------------------------------
Fax | 901-682-7243
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6005 PARK AVE STE 702
-----------------------------------------------------
City | MEMPHIS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38119-5217
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-682-7241
-----------------------------------------------------
Fax | 901-682-7243
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CARDIOLOGY
-----------------------------------------------------
Name | DR. LEE EDWIN FAULKNER
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 901-682-7241
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RC0000X
-----------------------------------------------------
Taxonomy Name | Cardiovascular Disease Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------