Provider Demographics
NPI:1558315861
Name:BLAKELY, MARTIN L (MD)
Entity Type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:L
Last Name:BLAKELY
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 1:3841 GREEN HILLS VILLAGE DR STE 200
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37215-2691
Mailing Address - Country:US
Mailing Address - Phone:615-322-3000
Mailing Address - Fax:
Practice Address - Street 1:7102 DOCTORS OFFICE TOWER
Practice Address - Street 2:2200 CHILDREN'S WAY
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37232-0001
Practice Address - Country:US
Practice Address - Phone:615-936-1050
Practice Address - Fax:615-936-1046
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD212012086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07578394Medicaid
AR154178001Medicaid
TN3891672Medicaid
AR154178001Medicaid
MS07578394Medicaid