MEDICARE: CODY'S CENTER OF HOPE, DEDICATED PEDIATRIC CARE, PC

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	208000000X	Pediatrics Physician

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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1740778166
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CODY'S CENTER OF HOPE, DEDICATED PEDIATRIC CARE, PC

Provider Business Mailing Address
First Line	:	PO BOX 381442
Second Line	:
City	:	GERMANTOWN
State	:	TN
Zip	:	38183-1442
Country	:	US
Telephone Number	:	901-350-2639
Fax Number	:	901-249-4563

Provider Business Practice Location Address
First Line	:	2565 HORIZON LAKE DR STE 114
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38133-8113
Country	:	US
Telephone Number	:	901-350-2639
Fax Number	:	901-249-4563

Authorized Official
Title or Position	:	PRESIDENT
Name	:	LORI R HOLTZMAN
Credential	:
Telephone Number	:	901-350-2639

Provider Enumeration Date	:	05/01/2018
Last Update Date	:	03/22/2022

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