Provider Demographics
NPI:1376623819
Name:BLACKETT, MELROSE INGLE (MD)
Entity Type:Individual
Prefix:
First Name:MELROSE
Middle Name:INGLE
Last Name:BLACKETT
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 1:965 RIDGE LAKE BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-9446
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:901-227-8591
Practice Address - Street 1:6215 HUMPHREYS BLVD STE 300
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-2382
Practice Address - Country:US
Practice Address - Phone:901-757-0229
Practice Address - Fax:901-757-9503
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000015010207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3726929Medicaid
A97135Medicare UPIN
A97135Medicare UPIN