Provider Demographics
NPI:1386039691
Name:MYERS, MICHELE POLISKIN (MD)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:POLISKIN
Last Name:MYERS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MICHELE
Other - Middle Name:CARA
Other - Last Name:POLISKIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
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:
Practice Address - Street 1:1225 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-2064
Practice Address - Country:US
Practice Address - Phone:601-292-4639
Practice Address - Fax:601-968-1310
Is Sole Proprietor?:No
Enumeration Date:2015-04-02
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS26736208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06783777Medicaid