Provider Demographics
NPI:1578848990
Name:ENT MEMPHIS
Entity type:Organization
Organization Name:ENT MEMPHIS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDE
Authorized Official - Middle Name:HARRIS
Authorized Official - Last Name:LAZAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:901-821-4317
Mailing Address - Street 1:791 ESTATE PL
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-0600
Mailing Address - Country:US
Mailing Address - Phone:901-821-4300
Mailing Address - Fax:901-821-4373
Practice Address - Street 1:791 ESTATE PL
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-0600
Practice Address - Country:US
Practice Address - Phone:901-821-4300
Practice Address - Fax:901-821-4373
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-17
Last Update Date:2011-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN016275174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3014587Medicaid
TN3014589Medicare PIN
TN3014587Medicaid