Healthcare Provider Details

I. General information

NPI: 1891893020
Provider Name (Legal Business Name): MICHAEL A REBOLLEDO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 03/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

848 ADAMS AVE L400
MEMPHIS TN
38103-2816
US

IV. Provider business mailing address

51 N DUNLAP ST G145
MEMPHIS TN
38105-4625
US

V. Phone/Fax

Practice location:
  • Phone: 901-287-7337
  • Fax: 901-287-4646
Mailing address:
  • Phone: 901-287-5594
  • Fax: 901-287-6804

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License NumberA52896
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number54187
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: