MEDICARE: MID-SOUTH TRANSPLANT FOUNDATION, INC.

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	291U00000X	Clinical Medical Laboratory	0000002214	TN

General Provider Information

NPI Number	:	1386844504
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MID-SOUTH TRANSPLANT FOUNDATION, INC.

Provider Business Mailing Address
First Line	:	8001 CENTERVIEW PKWY STE 302
Second Line	:
City	:	CORDOVA
State	:	TN
Zip	:	38018-4228
Country	:	US
Telephone Number	:	901-328-4438
Fax Number	:	901-328-4462

Provider Business Practice Location Address
First Line	:	8001 CENTERVIEW PKWY STE 302
Second Line	:
City	:	CORDOVA
State	:	TN
Zip	:	38018-4228
Country	:	US
Telephone Number	:	901-328-4438
Fax Number	:	901-328-4462

Authorized Official
Title or Position	:	INTERIM EXECUTIVE DIRECTOR
Name	:	MRS. KIM VAN FRANK
Credential	:
Telephone Number	:	901-328-4438

Provider Enumeration Date	:	07/25/2007
Last Update Date	:	10/06/2008

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