MEDICARE: MID SOUTH AMBULATORY SERVICES, LLC

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	343900000X	Non-emergency Medical Transport (VAN)

General Provider Information

NPI Number	:	1104249127
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MID SOUTH AMBULATORY SERVICES, LLC

Provider Business Mailing Address
First Line	:	5628 MURRAY AVE STE 1
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38119-3876
Country	:	US
Telephone Number	:	901-237-9791
Fax Number	:	901-257-7097

Provider Business Practice Location Address
First Line	:	5628 MURRAY AVE STE 1
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38119-3876
Country	:	US
Telephone Number	:	901-237-9791
Fax Number	:

Authorized Official
Title or Position	:	OWNER, MEMBER
Name	:	MRS. TYRA ZANDERS TAYLOR
Credential	:
Telephone Number	:	901-237-9791

Provider Enumeration Date	:	01/27/2014
Last Update Date	:	04/17/2021

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