MEDICARE: DR. MARY CECELIA PORTIS M.D.

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	207RG0100X	Gastroenterology Physician	MD26819	TN

General Provider Information

NPI Number	:	1265415822
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARY CECELIA PORTIS M.D.

Provider Business Mailing Address
First Line	:	6005 PARK AVE
Second Line	:	SUITE 323B
City	:	MEMPHIS
State	:	TN
Zip	:	38119-5202
Country	:	US
Telephone Number	:	901-684-5500
Fax Number	:	901-684-5518

Provider Business Practice Location Address
First Line	:	6005 PARK AVE
Second Line	:	SUITE 323B
City	:	MEMPHIS
State	:	TN
Zip	:	38119-5202
Country	:	US
Telephone Number	:	901-684-5500
Fax Number	:	901-684-5518

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

Provider Enumeration Date	:	11/28/2005
Last Update Date	:	07/08/2007

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