Provider Demographics
NPI:1447678776
Name:PERISCO WOFFORD MD PLLC
Entity type:Organization
Organization Name:PERISCO WOFFORD MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PERISCO
Authorized Official - Middle Name:
Authorized Official - Last Name:WOFFORD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:901-345-1454
Mailing Address - Street 1:4567 MILLBRANCH RD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38116-7437
Mailing Address - Country:US
Mailing Address - Phone:901-345-1454
Mailing Address - Fax:901-345-1456
Practice Address - Street 1:4567 MILLBRANCH RD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38116-7437
Practice Address - Country:US
Practice Address - Phone:901-345-1454
Practice Address - Fax:901-345-1456
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-03
Last Update Date:2014-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000037436261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center