Provider Demographics
NPI:1164413928
Name:MICHAEL, LATTIMORE MADISON II (MD)
Entity Type:Individual
Prefix:
First Name:LATTIMORE
Middle Name:MADISON
Last Name:MICHAEL
Suffix:II
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:L
Other - Middle Name:MADISON
Other - Last Name:MICHAEL
Other - Suffix:II
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:6325 HUMPHREYS BLVD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-2300
Mailing Address - Country:US
Mailing Address - Phone:901-522-7700
Mailing Address - Fax:901-522-2600
Practice Address - Street 1:6325 HUMPHREYS BLVD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-2300
Practice Address - Country:US
Practice Address - Phone:901-522-7700
Practice Address - Fax:901-259-2022
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS19724207T00000X
TN32108207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS008470507Medicaid
TN3328581Medicaid
MS512I140002Medicare PIN
TN3328581Medicare ID - Type Unspecified