Organization
MODERN GYNECOLOGY AND REPRODUCTIVE HEALTH PC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. SUSAN NORTHEN LACY MD (PHYSICIAN OWNER)
(901) 289-0915
Entity
Organization
Contact information
Practice address
1407 UNION AVE STE 1401, MEMPHIS, TN 38104-3667
(901) 701-1777
(901) 701-1778
Mailing address
1407 UNION AVE STE 1401, MEMPHIS, TN 38104-3667
(901) 483-0619
Taxonomy
Speciality
Code
Description
License number
State
207VG0400X
Gynecology Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
Q053117
—
TN
Enumeration date
07/27/2019
Last updated
11/01/2019
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