Healthcare Provider Details

I. General information

NPI: 1376623819
Provider Name (Legal Business Name): MELROSE INGLE BLACKETT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 04/15/2021
Certification Date: 04/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6215 HUMPHREYS BLVD STE 300
MEMPHIS TN
38120-2382
US

IV. Provider business mailing address

965 RIDGE LAKE BLVD STE 103
MEMPHIS TN
38120-9446
US

V. Phone/Fax

Practice location:
  • Phone: 901-757-0229
  • Fax: 901-757-9503
Mailing address:
  • Phone:
  • Fax: 901-227-8591

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number0000015010
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: