Provider Demographics
NPI:1235164468
Name:TALLEY, MARK A (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:TALLEY
Suffix:
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 1:210 25TH AVE N STE 602
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37203-1631
Mailing Address - Country:US
Mailing Address - Phone:615-312-1479
Mailing Address - Fax:615-320-3259
Practice Address - Street 1:210 25TH AVE N STE 602
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37203
Practice Address - Country:US
Practice Address - Phone:615-312-1479
Practice Address - Fax:615-320-3259
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2018-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN178192085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN300050345OtherRR MCARE-ADR
TN300063281OtherRR MCARE-CI
TN3029755OtherADR BC/BS OF TN
TN3036089Medicaid
AL009932806Medicaid
TN3049719OtherPLAZA BC/BS OF TN
GA000674561Medicaid
AL009932806Medicaid
TN3036089Medicaid
TN3049719OtherPLAZA BC/BS OF TN
TN300063281Medicare PIN