1295761203 NPI number — PENN Q JOE MD

Table of content: PENN Q JOE MD (NPI 1295761203)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295761203 NPI number — PENN Q JOE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOE
Provider First Name:
PENN
Provider Middle Name:
Q
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1295761203
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/20/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8110 N BROTHER BLVD STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BARTLETT
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38133-2760
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
901-255-5221
Provider Business Mailing Address Fax Number:
901-373-4511

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6215 HUMPHREYS BLVD
Provider Second Line Business Practice Location Address:
#401
Provider Business Practice Location Address City Name:
MEMPHIS
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38120-2367
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-767-8442
Provider Business Practice Location Address Fax Number:
901-684-6260
Provider Enumeration Date:
06/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , with the licence number:  MD013391 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2001739 . This is a "BCBS" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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