MEDICARE: DR. TAHERE POURMOTABBED PHD

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	103TC0700X	Clinical Psychologist	P0000002344	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4094352	OTHER	TN	BCBS OF TN
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1649343765
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TAHERE POURMOTABBED PHD

Provider Business Mailing Address
First Line	:	8110 CORDOVA RD
Second Line	:
City	:	CORDOVA
State	:	TN
Zip	:	38016-0520
Country	:	US
Telephone Number	:	901-757-0568
Fax Number	:	901-754-8247

Provider Business Practice Location Address
First Line	:	8110 CORDOVA RD
Second Line	:
City	:	CORDOVA
State	:	TN
Zip	:	38016-0520
Country	:	US
Telephone Number	:	901-757-0568
Fax Number	:	901-754-8247

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

Provider Enumeration Date	:	11/16/2006
Last Update Date	:	07/08/2007

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