=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760482434
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PEDIATRIC EMERGENCY SPECIALISTS, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/26/2005
-----------------------------------------------------
Last Update Date | 01/03/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 848 ADAMS AVE
-----------------------------------------------------
City | MEMPHIS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38103-2816
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-287-6112
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5885 AIRLINE RD #1011
-----------------------------------------------------
City | ARLINGTON
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38002-5127
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-317-7360
-----------------------------------------------------
Fax | 901-317-7585
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. WILLIAM R HANNA JR.
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 901-287-6112
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207PP0204X
-----------------------------------------------------
Taxonomy Name | Pediatric Emergency Medicine (Emergency Medicine) Physician
-----------------------------------------------------
License Number | N/A
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------