Healthcare Provider Details

I. General information

NPI: 1417901570
Provider Name (Legal Business Name): MARTHA K TIBBS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 10/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5959 PARK AVE RADIOLOGY DEPARTMENT
MEMPHIS TN
38119-5200
US

IV. Provider business mailing address

PO BOX 2044 DEPT 2600
MEMPHIS TN
38101-2044
US

V. Phone/Fax

Practice location:
  • Phone: 901-765-3212
  • Fax: 901-765-1727
Mailing address:
  • Phone: 901-765-3212
  • Fax: 901-765-1727

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD029014
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: