Provider Demographics
NPI:1447269709
Name:NEPHROLOGY SERVICES MEDICAL GROUP OF MEMPHIS PC
Entity type:Organization
Organization Name:NEPHROLOGY SERVICES MEDICAL GROUP OF MEMPHIS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BOBBY
Authorized Official - Middle Name:J
Authorized Official - Last Name:KELLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:901-747-3501
Mailing Address - Street 1:6025 WALNUT GROVE RD STE 314
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-2123
Mailing Address - Country:US
Mailing Address - Phone:901-747-3501
Mailing Address - Fax:901-747-3516
Practice Address - Street 1:6025 WALNUT GROVE RD STE 314
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-2123
Practice Address - Country:US
Practice Address - Phone:901-747-3501
Practice Address - Fax:901-747-3516
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2018-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09015986Medicaid
TN4008478OtherBLUE CROSS
TN4008478OtherBLUE CROSS