Provider Demographics
NPI:1588671085
Name:MARTIN, MICHAEL GARY (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:GARY
Last Name:MARTIN
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 1:100 N HUMPHREYS BLVD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-2146
Mailing Address - Country:US
Mailing Address - Phone:901-683-0055
Mailing Address - Fax:901-685-9718
Practice Address - Street 1:100 N HUMPHREYS BLVD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-2146
Practice Address - Country:US
Practice Address - Phone:901-683-0055
Practice Address - Fax:901-685-9718
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2011-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006013748207RH0003X
MS20639207RH0003X
TN44541207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02209015Medicaid
AR177683001Medicaid
MO1588671085Medicaid
TN1513165Medicaid
TN3041716Medicare PIN
MS02209015Medicaid