Provider Demographics
NPI:1053416776
Name:COLLIERVILLE MEDICAL SPECIALISTS
Entity type:Organization
Organization Name:COLLIERVILLE MEDICAL SPECIALISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHAIRMAN OF THE BOARD
Authorized Official - Prefix:MR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:CLARENCE
Authorized Official - Last Name:JEFFERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:901-854-1877
Mailing Address - Street 1:526 HALLE PARK DRIVE
Mailing Address - Street 2:
Mailing Address - City:COLLIERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38017-7085
Mailing Address - Country:US
Mailing Address - Phone:901-854-1877
Mailing Address - Fax:901-854-6181
Practice Address - Street 1:526 HALLE PARK DRIVE
Practice Address - Street 2:
Practice Address - City:COLLIERVILLE
Practice Address - State:TN
Practice Address - Zip Code:38017-7085
Practice Address - Country:US
Practice Address - Phone:901-854-1877
Practice Address - Fax:901-854-6181
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty