Basic Information
| Provider Information | |||||||||
| NPI: | 1952356206 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KIRSCH | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | WOOD | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | P O BOX 1000 DEPT 351 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381480001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9017589900 | ||||||||
| FaxNumber: | 9017522335 | ||||||||
| Practice Location | |||||||||
| Address1: | 4250 BETHEL RD | ||||||||
| Address2: | |||||||||
| City: | OLIVE BRANCH | ||||||||
| State: | MS | ||||||||
| PostalCode: | 38654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9015161290 | ||||||||
| FaxNumber: | 9015161220 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2006 | ||||||||
| LastUpdateDate: | 09/04/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | 40980 | TN | N | Allopathic & Osteopathic Physicians | Hospitalist | 207Q00000X | MD40980 | TN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1952356206 | 05 | TN | MEDICAID | Q018320 | 05 | TN | MEDICAID |