MEDICARE: MEMPHIS GASTROENTEROLOGY ENDOSCOPY

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	261QE0800X	Endoscopy Clinic/Center	0000000066	TN

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	490003309	OTHER	TN	RAIL ROAD MEDICARE

General Provider Information

NPI Number	:	1902808488
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEMPHIS GASTROENTEROLOGY ENDOSCOPY

Provider Business Mailing Address
First Line	:	8000 WOLF RIVER BLVD
Second Line	:	SUITE 200
City	:	GERMANTOWN
State	:	TN
Zip	:	38138-1755
Country	:	US
Telephone Number	:	901-747-3630
Fax Number	:	901-747-4039

Provider Business Practice Location Address
First Line	:	8000 WOLF RIVER BLVD
Second Line	:	SUITE 200
City	:	GERMANTOWN
State	:	TN
Zip	:	38138
Country	:	US
Telephone Number	:	901-747-3630
Fax Number	:	901-747-4039

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MRS. ANGIE B. WILSON
Credential	:
Telephone Number	:	901-747-3630

Provider Enumeration Date	:	08/14/2005
Last Update Date	:	03/23/2012

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Directions to “MEMPHIS GASTROENTEROLOGY ENDOSCOPY ” Practice Location

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