Provider Demographics
NPI:1417229428
Name:MEDSOUTH
Entity type:Organization
Organization Name:MEDSOUTH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:THACRA
Authorized Official - Middle Name:
Authorized Official - Last Name:GOLDE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-497-1543
Mailing Address - Street 1:6025 STAGE RD
Mailing Address - Street 2:SUITE # 42-372
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38134-8374
Mailing Address - Country:US
Mailing Address - Phone:901-497-1543
Mailing Address - Fax:888-499-4391
Practice Address - Street 1:4745 POPLAR AVE
Practice Address - Street 2:SUITE # 303
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38117-4430
Practice Address - Country:US
Practice Address - Phone:901-497-1543
Practice Address - Fax:888-499-4391
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-07
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies