Provider Demographics
NPI:1992702922
Name:GERIATRIC GROUP OF MEMPHIS,PLLC
Entity type:Organization
Organization Name:GERIATRIC GROUP OF MEMPHIS,PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MGR
Authorized Official - Prefix:
Authorized Official - First Name:JENNY WREN
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCALLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-725-0872
Mailing Address - Street 1:2714 UNION AVENUE EXT
Mailing Address - Street 2:SUITE 150
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38112-4436
Mailing Address - Country:US
Mailing Address - Phone:901-725-0872
Mailing Address - Fax:901-278-6934
Practice Address - Street 1:2714 UNION AVENUE EXT
Practice Address - Street 2:SUITE 150
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38112-4436
Practice Address - Country:US
Practice Address - Phone:901-725-0872
Practice Address - Fax:901-278-6934
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-05
Last Update Date:2016-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3726736Medicaid
TN3726736Medicare PIN