Provider Demographics
NPI:1356318661
Name:THRELKELD, MICHAEL G (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:G
Last Name:THRELKELD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6799 GREAT OAKS RD STE 250
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38138-2584
Mailing Address - Country:US
Mailing Address - Phone:901-685-3490
Mailing Address - Fax:901-685-3499
Practice Address - Street 1:6029 WALNUT GROVE RD STE C002
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-2112
Practice Address - Country:US
Practice Address - Phone:901-685-3490
Practice Address - Fax:901-685-3499
Is Sole Proprietor?:No
Enumeration Date:2006-03-06
Last Update Date:2019-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD15116207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR155434001Medicaid
MS00017990Medicaid
TN3721649Medicaid
TN3042007Medicaid
TN3042007Medicaid
C74219Medicare UPIN
AR115434001OtherARKANSAS MEDICAID
TN3155313OtherBCBST
TN3042006Medicare ID - Type UnspecifiedINDIVIDUAL MEDICARE
TN3042005Medicaid