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NPI Code Detail

MEDICARE: GASTROENTEROLOGY CENTER OF THE MIDSOUTH PLLC

MEDICARE: GASTROENTEROLOGY CENTER OF THE MIDSOUTH PLLC
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
1207ZP0102XAnatomic Pathology & Clinical Pathology Physician
2367500000XCertified Registered Nurse Anesthetist
3363L00000XNurse Practitioner
4207RG0100XGastroenterology Physician

General Provider Information

NPI Number : 1417932492
Entity Type Code : Organization
Provider Name (Legal Business Name) : GASTROENTEROLOGY CENTER OF THE MIDSOUTH PLLC
Provider Business Mailing Address
First Line : ONE GI CREDENTIALING DEPARTMENT
Second Line : PO BOX 381468
City : GERMANTOWN
State : TN
Zip : 38183-1468
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 8000 WOLF RIVER BLVD STE 200
Second Line :
City : GERMANTOWN
State : TN
Zip : 38138-1755
Country : US
Telephone Number : 901-747-3630
Fax Number :
Authorized Official
Title or Position : DIRECTOR, CREDENTIALING
Name : KRISTINA MATERNA
Credential :
Telephone Number : 901-377-8219
Provider Enumeration Date : 12/13/2005
Last Update Date : 02/03/2026

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