Provider Demographics
| NPI: | 1124588793 |
|---|---|
| Name: | POPLAR AVENUE CLINIC PLLC |
| Entity type: | Organization |
| Organization Name: | POPLAR AVENUE CLINIC PLLC |
| Other - Org Name: | <UNAVAIL> |
| Other - Org Type: | |
| Authorized Official - Title/Position: | OFFICE MANAGER |
| Authorized Official - Prefix: | |
| Authorized Official - First Name: | HUDA |
| Authorized Official - Middle Name: | |
| Authorized Official - Last Name: | ALAEDDIN |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | |
| Authorized Official - Phone: | 901-870-8840 |
| Mailing Address - Street 1: | PO BOX 172344 |
| Mailing Address - Street 2: | |
| Mailing Address - City: | MEMPHIS |
| Mailing Address - State: | TN |
| Mailing Address - Zip Code: | 38187-2344 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 901-870-8840 |
| Mailing Address - Fax: | 901-552-5891 |
| Practice Address - Street 1: | 6584 POPLAR AVE STE 400 |
| Practice Address - Street 2: | |
| Practice Address - City: | MEMPHIS |
| Practice Address - State: | TN |
| Practice Address - Zip Code: | 38138-3687 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 901-300-6713 |
| Practice Address - Fax: | 901-552-5891 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2019-03-20 |
| Last Update Date: | 2022-09-06 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 207VX0201X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecologic Oncology | Group - Multi-Specialty |
| No | 2085R0204X | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | Group - Multi-Specialty |
| No | 2086S0129X | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | Group - Multi-Specialty |
| No | 261QF0050X | Ambulatory Health Care Facilities | Clinic/Center | Family Planning, Non-Surgical | Group - Multi-Specialty |
| No | 261QM1300X | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | |
| No | 261QM2500X | Ambulatory Health Care Facilities | Clinic/Center | Medical Specialty | |
| No | 261QP2300X | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | |
| No | 261QU0200X | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care | |
| No | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Group - Multi-Specialty | |
| No | 363AM0700X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | Group - Multi-Specialty |
| No | 363AS0400X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | Group - Multi-Specialty |
| No | 363LW0102X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health | Group - Multi-Specialty |
| No | 367500000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| TN | 893541 | Medicaid | |
| MS | 6528091 | Medicaid |
