MEDICARE: PERISCO WOFFORD MD 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
1	261Q00000X	Clinic/Center	MD0000037436	TN

General Provider Information

NPI Number	:	1447678776
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PERISCO WOFFORD MD PLLC

Provider Business Mailing Address
First Line	:	4567 MILLBRANCH RD
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38116-7437
Country	:	US
Telephone Number	:	901-345-1454
Fax Number	:	901-345-1456

Provider Business Practice Location Address
First Line	:	4567 MILLBRANCH RD
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38116-7437
Country	:	US
Telephone Number	:	901-345-1454
Fax Number	:	901-345-1456

Authorized Official
Title or Position	:	OWNER
Name	:	PERISCO WOFFORD
Credential	:	MD
Telephone Number	:	901-345-1454

Provider Enumeration Date	:	04/03/2014
Last Update Date	:	04/03/2014

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