Provider Demographics
NPI:1629026471
Name:CHAMBLISS, MARSHALL L (MD)
Entity Type:Individual
Prefix:DR
First Name:MARSHALL
Middle Name:L
Last Name:CHAMBLISS
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 1:1125 N CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27401-1007
Mailing Address - Country:US
Mailing Address - Phone:336-832-8035
Mailing Address - Fax:
Practice Address - Street 1:1125 N CHURCH ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401-1007
Practice Address - Country:US
Practice Address - Phone:336-832-8035
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2021-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9600329207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC4308504OtherAETNA
NC21961OtherBCBSNC
NC8921961Medicaid
NC14725OtherPARTNERS MEDICARE
NC64949OtherMEDCOST
NC4308504OtherAETNA
E23237Medicare UPIN