Provider Demographics
NPI:1134185739
Name:BISHOP, MARILYN A (MD)
Entity type:Individual
Prefix:
First Name:MARILYN
Middle Name:A
Last Name:BISHOP
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 MED TECH PKWY
Mailing Address - Street 2:SUITE 108
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-2278
Mailing Address - Country:US
Mailing Address - Phone:423-915-5033
Mailing Address - Fax:423-952-3777
Practice Address - Street 1:200 MED TECH PKWY
Practice Address - Street 2:SUITE 108
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-2278
Practice Address - Country:US
Practice Address - Phone:423-915-5033
Practice Address - Fax:423-952-3777
Is Sole Proprietor?:No
Enumeration Date:2006-04-22
Last Update Date:2017-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD215392083X0100X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3074352OtherBCBS
VA1134185739Medicaid
TNQ003169Medicaid
TN3062667Medicaid
TNQ003169Medicaid
TN3074352OtherBCBS