MEDICARE: METHODIST LE BONHEUR COMMUNITY OUTREACH

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	363LC1500X	Community Health Nurse Practitioner
2	208000000X	Pediatrics Physician

General Provider Information

NPI Number	:	1174872139
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	METHODIST LE BONHEUR COMMUNITY OUTREACH

Provider Business Mailing Address
First Line	:	1535 VANN DR
Second Line	:
City	:	JACKSON
State	:	TN
Zip	:	38305-2095
Country	:	US
Telephone Number	:	731-499-0977
Fax Number	:	731-499-9939

Provider Business Practice Location Address
First Line	:	77 STONEBRIDGE BLVD
Second Line	:
City	:	JACKSON
State	:	TN
Zip	:	38305-2165
Country	:	US
Telephone Number	:	901-287-5961
Fax Number	:

Authorized Official
Title or Position	:	MANAGER OF OPERATIONS
Name	:	PAM DENISE BURNETT
Credential	:
Telephone Number	:	731-984-9963

Provider Enumeration Date	:	09/06/2012
Last Update Date	:	08/19/2019

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Directions to “METHODIST LE BONHEUR COMMUNITY OUTREACH ” Practice Location

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