Provider Demographics
NPI:1063509719
Name:TYNES, MARSHALL SCOTT (DO)
Entity Type:Individual
Prefix:DR
First Name:MARSHALL
Middle Name:SCOTT
Last Name:TYNES
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 22ND AVE
Mailing Address - Street 2:MEDICAL TOWERS III
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39301-3223
Mailing Address - Country:US
Mailing Address - Phone:601-483-5322
Mailing Address - Fax:601-581-2289
Practice Address - Street 1:1600 22ND AVE
Practice Address - Street 2:MEDICAL TOWERS III
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-3223
Practice Address - Country:US
Practice Address - Phone:601-483-5322
Practice Address - Fax:601-581-2289
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS14897207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0117444Medicaid
AL009700450OtherALMCD
279588OtherTRICARE
AL073075294TYNOtherAL BCBS
MS0117444Medicaid
279588OtherTRICARE