Provider Demographics
NPI:1447620901
Name:JIM PANG MD PLLC
Entity type:Organization
Organization Name:JIM PANG MD PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:HAMILTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-752-4900
Mailing Address - Street 1:65 GERMANTOWN CT STE 402
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38018-4275
Mailing Address - Country:US
Mailing Address - Phone:901-752-4900
Mailing Address - Fax:901-752-4902
Practice Address - Street 1:65 GERMANTOWN CT STE 402
Practice Address - Street 2:
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38018
Practice Address - Country:US
Practice Address - Phone:901-752-4900
Practice Address - Fax:901-752-4902
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-28
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN017659261Q00000X
261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ035474Medicaid