Provider Demographics
NPI:1063509719
Name:TYNES, MARSHALL SCOTT (DO)
Entity type:Individual
Prefix:DR
First Name:MARSHALL
Middle Name:SCOTT
Last Name:TYNES
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 749215
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-9215
Mailing Address - Country:US
Mailing Address - Phone:901-226-3186
Mailing Address - Fax:
Practice Address - Street 1:1600 22ND AVE
Practice Address - Street 2:MEDICAL TOWERS III
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-3223
Practice Address - Country:US
Practice Address - Phone:601-483-5322
Practice Address - Fax:601-581-2289
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MS14897207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL073075294TYNOtherAL BCBS
AL009700450OtherALMCD
MS0117444Medicaid
279588OtherTRICARE
MS0117444Medicaid
279588OtherTRICARE