Provider Demographics
NPI:1255364956
Name:BOULDIN, MARSHALL J IV (MD)
Entity type:Individual
Prefix:
First Name:MARSHALL
Middle Name:J
Last Name:BOULDIN
Suffix:IV
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3322 W END AVE
Mailing Address - Street 2:11TH FLOOR
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37203-1031
Mailing Address - Country:US
Mailing Address - Phone:615-515-9880
Mailing Address - Fax:
Practice Address - Street 1:1040 RIVER OAKS DR
Practice Address - Street 2:SUITE 302
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39232-9530
Practice Address - Country:US
Practice Address - Phone:601-939-9923
Practice Address - Fax:601-939-9924
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2014-03-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MS12970207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00120235Medicaid
MSRR 110204015OtherRAILROAD
MSE92754Medicare UPIN
MS512I110048Medicare PIN