Provider Demographics
NPI:1356893226
Name:MID SOUTH MED, LLC
Entity type:Organization
Organization Name:MID SOUTH MED, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:OLIVER
Authorized Official - Middle Name:
Authorized Official - Last Name:BANKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-497-1040
Mailing Address - Street 1:9160 HIGHWAY 64
Mailing Address - Street 2:SUITE 5
Mailing Address - City:LAKELAND
Mailing Address - State:TN
Mailing Address - Zip Code:38002-4766
Mailing Address - Country:US
Mailing Address - Phone:901-623-3587
Mailing Address - Fax:901-213-9235
Practice Address - Street 1:9160 HIGHWAY 64
Practice Address - Street 2:SUITE 5
Practice Address - City:LAKELAND
Practice Address - State:TN
Practice Address - Zip Code:38002-4766
Practice Address - Country:US
Practice Address - Phone:901-623-3587
Practice Address - Fax:901-213-9235
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-26
Last Update Date:2016-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000006816261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care