Basic Information
| Provider Information | |||||||||
| NPI: | 1417108796 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LONDON CORPORATON | ||||||||
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| Mailing Information | |||||||||
| Address1: | 23 SOUTH PAULINE STREET | ||||||||
| Address2: | SUITE 709 | ||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381043121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9015779467 | ||||||||
| FaxNumber: | 9013626618 | ||||||||
| Practice Location | |||||||||
| Address1: | 23 SOUTH PAULINE STREET | ||||||||
| Address2: | SUITE 709 | ||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381043121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9015779467 | ||||||||
| FaxNumber: | 9013626618 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2008 | ||||||||
| LastUpdateDate: | 04/27/2009 | ||||||||
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| AuthorizedOfficialLastName: | JASTER | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9015779467 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 26376 | TN | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 1003005885 | 01 | TN | NPI | OTHER | 3098864 | 05 | TN | MEDICAID | 1510854 | 05 | TN | MEDICAID |