Provider Demographics
NPI:1306884911
Name:MEMPHIS OBSTETRICS AND GYNECOLOGICAL ASSOCIATION PC
Entity type:Organization
Organization Name:MEMPHIS OBSTETRICS AND GYNECOLOGICAL ASSOCIATION PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:W
Authorized Official - Last Name:GIBSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-373-8949
Mailing Address - Street 1:8110 N BROTHER BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:BARTLETT
Mailing Address - State:TN
Mailing Address - Zip Code:38133-2760
Mailing Address - Country:US
Mailing Address - Phone:901-255-5221
Mailing Address - Fax:901-373-4511
Practice Address - Street 1:8110 N BROTHER BLVD STE 100
Practice Address - Street 2:
Practice Address - City:BARTLETT
Practice Address - State:TN
Practice Address - Zip Code:38133-2760
Practice Address - Country:US
Practice Address - Phone:901-373-9221
Practice Address - Fax:901-202-5994
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-04
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01933242Medicaid
MS09581870Medicaid
CB9230OtherRAILROAD MEDICARE
TN3387157Medicaid
TN3387157Medicare PIN