Provider Demographics
NPI:1124254404
Name:FAIRCLOTH, MICHELE KAMP (MD)
Entity type:Individual
Prefix:
First Name:MICHELE
Middle Name:KAMP
Last Name:FAIRCLOTH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MICHELE
Other - Middle Name:FRANCES
Other - Last Name:KAMP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1211 UNION AVE STE 330
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-6655
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7691 POPLAR AVE
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-3904
Practice Address - Country:US
Practice Address - Phone:901-516-1290
Practice Address - Fax:901-516-1220
Is Sole Proprietor?:No
Enumeration Date:2009-06-01
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN48481208M00000X, 207R00000X
MS23748207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03259503Medicaid
TN4330515OtherBCBS
AR193853001Medicaid
TN1529195Medicaid
TNP01133352OtherRAILROAD MEDICARE
TN1529195Medicaid