Provider Demographics
NPI:1326140237
Name:MARDIS, MARLAH H (MD)
Entity Type:Individual
Prefix:
First Name:MARLAH
Middle Name:H
Last Name:MARDIS
Suffix:
Gender:F
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:PO BOX 1000
Mailing Address - Street 2:DEPT. 96
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38148-0001
Mailing Address - Country:US
Mailing Address - Phone:901-756-5565
Mailing Address - Fax:901-756-5564
Practice Address - Street 1:1785 NONCONNAH BLVD
Practice Address - Street 2:#120
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38132-2104
Practice Address - Country:US
Practice Address - Phone:901-345-6700
Practice Address - Fax:901-345-6755
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2010-06-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TN25693207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4749410OtherCIGNA
TN510081OtherUAHC/OMNICARE
TN3083714Medicaid
TN3092614OtherBCBST
TN4597594OtherAETNA HMO
TN3083714Medicare PIN
TN510081OtherUAHC/OMNICARE