Provider Demographics
NPI:1457490591
Name:MARVIN ASBURY BLANTON III MD PC
Entity Type:Organization
Organization Name:MARVIN ASBURY BLANTON III MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GLORIA
Authorized Official - Middle Name:FAYE
Authorized Official - Last Name:ISBELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:731-885-6662
Mailing Address - Street 1:2379 WALKER TANNER RD
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:TN
Mailing Address - Zip Code:38261-8209
Mailing Address - Country:US
Mailing Address - Phone:731-885-6662
Mailing Address - Fax:731-885-6643
Practice Address - Street 1:1720 EAST REELFOOT AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:UNION CITY
Practice Address - State:TN
Practice Address - Zip Code:38261-6004
Practice Address - Country:US
Practice Address - Phone:731-885-6662
Practice Address - Fax:731-885-6643
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD00005749207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3724967Medicaid
TN3724967Medicare ID - Type Unspecified
TN3724967Medicaid