Basic Information
| Provider Information | |||||||||
| NPI: | 1891893020 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REBOLLEDO | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 51 N DUNLAP ST | ||||||||
| Address2: | G145 | ||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381054625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9012875594 | ||||||||
| FaxNumber: | 9012876804 | ||||||||
| Practice Location | |||||||||
| Address1: | 848 ADAMS AVE | ||||||||
| Address2: | L400 | ||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381032816 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9012877337 | ||||||||
| FaxNumber: | 9012874646 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 03/18/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0202X | A52896 | CA | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Cardiology | 2080P0202X | 54187 | TN | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Cardiology |
ID Information
| ID | Type | State | Issuer | Description | 00A528960 | 05 | CA | MEDICAID |