MEDICARE: DR. SUDHA R PRASAD MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	12949	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	25923	OTHER	TN	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1013083781
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SUDHA R PRASAD MD

Provider Business Mailing Address
First Line	:	PO BOX 17962
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38187-7962
Country	:	US
Telephone Number	:	901-324-3984
Fax Number	:	901-454-1655

Provider Business Practice Location Address
First Line	:	3836 PARK AVE
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38111-6633
Country	:	US
Telephone Number	:	901-324-3984
Fax Number	:	901-454-1655

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/27/2006
Last Update Date	:	03/22/2013

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