Provider Demographics
NPI:1386478949
Name:PREVENTIVEMD, PLLC
Entity type:Organization
Organization Name:PREVENTIVEMD, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:
Authorized Official - Last Name:WRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-201-5675
Mailing Address - Street 1:1407 UNION AVE STE 305
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-3615
Mailing Address - Country:US
Mailing Address - Phone:901-609-2444
Mailing Address - Fax:
Practice Address - Street 1:4066 SUMMER AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38122-5262
Practice Address - Country:US
Practice Address - Phone:901-452-7391
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PREVENTIVEMD, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-08-27
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center