Provider Demographics
NPI:1992758882
Name:CONRAD PEARSON CLINIC PC
Entity type:Organization
Organization Name:CONRAD PEARSON CLINIC PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:A
Authorized Official - Last Name:DEGEORGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-252-3400
Mailing Address - Street 1:1325 WOLF PARK DR STE 103
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138-1759
Mailing Address - Country:US
Mailing Address - Phone:901-252-3411
Mailing Address - Fax:901-384-6422
Practice Address - Street 1:1325 WOLF PARK DR STE 102
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-1759
Practice Address - Country:US
Practice Address - Phone:901-252-3400
Practice Address - Fax:901-682-0047
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CONRAD PEARSON CLINIC PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-19
Last Update Date:2024-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNN/A FOR THE GROUP208800000X
261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Single Specialty
No208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR163577002Medicaid
TN3042605OtherBLUE CROSS TN
5608209OtherAETNA
AR5F646OtherBLUE CROSS AR
FL72409OtherBLUE CROSS FL
FLDD9156Medicare PIN
TN3042605OtherBLUE CROSS TN
MSCN3779Medicare ID - Type UnspecifiedRAILROAD MEDICARE
FL72409OtherBLUE CROSS FL
FLK8235Medicare ID - Type Unspecified
TNCC6179Medicare ID - Type UnspecifiedRAILROAD MEDICARE