Provider Demographics
NPI:1003853664
Name:BUCKLEY, MADISON H JR (MD)
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:H
Last Name:BUCKLEY
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 1000
Mailing Address - Street 2:DEPT 34
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38148-0001
Mailing Address - Country:US
Mailing Address - Phone:901-383-8860
Mailing Address - Fax:901-383-8985
Practice Address - Street 1:50 HUMPHREYS CTR
Practice Address - Street 2:SUITE 23
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-2369
Practice Address - Country:US
Practice Address - Phone:901-226-0810
Practice Address - Fax:901-383-8985
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2011-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0045322085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO201028107Medicaid
TN3035193Medicaid
MS00116063Medicaid
AR106855001Medicaid
MS00116063Medicaid
MO201028107Medicaid