Provider Demographics
NPI:1962056036
Name:MODERN GYNECOLOGY AND REPRODUCTIVE HEALTH PC
Entity type:Organization
Organization Name:MODERN GYNECOLOGY AND REPRODUCTIVE HEALTH PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:NORTHEN
Authorized Official - Last Name:LACY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:901-289-0915
Mailing Address - Street 1:1407 UNION AVE STE 1401
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-3667
Mailing Address - Country:US
Mailing Address - Phone:901-483-0619
Mailing Address - Fax:
Practice Address - Street 1:1407 UNION AVE STE 1401
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-3667
Practice Address - Country:US
Practice Address - Phone:901-701-1777
Practice Address - Fax:901-701-1778
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-27
Last Update Date:2019-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ053117Medicaid