MEDICARE: UNIVERSITY OF TENNESSEE

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	261QD1600X	Developmental Disabilities Clinic/Center	LM222M20956033	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1427064880
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UNIVERSITY OF TENNESSEE

Provider Business Mailing Address
First Line	:	920 MADISON AVE STE 939
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38103-3438
Country	:	US
Telephone Number	:	901-448-6511
Fax Number	:	901-448-3844

Provider Business Practice Location Address
First Line	:	920 MADISON AVE STE 939
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38103-3438
Country	:	US
Telephone Number	:	901-448-6511
Fax Number	:	901-448-3844

Authorized Official
Title or Position	:	DIRECTOR
Name	:	DR. BRUCE KEISLING
Credential	:	PHD
Telephone Number	:	901-448-6511

Provider Enumeration Date	:	07/31/2006
Last Update Date	:	08/14/2023

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Directions to “UNIVERSITY OF TENNESSEE ” Practice Location

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