=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639120876
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOTLEY INTERNAL MEDICINE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/12/2006
-----------------------------------------------------
Last Update Date | 08/24/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1264 WESLEY DR SUITE 201
-----------------------------------------------------
City | MEMPHIS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38116-6400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-332-2277
-----------------------------------------------------
Fax | 901-332-2270
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2153 DEPT 3252
-----------------------------------------------------
City | BIRMINGHAM
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35287-0002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-332-2277
-----------------------------------------------------
Fax | 901-332-2270
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | TODD MOTLEY
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 901-332-2277
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | MD0000033846
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------