Basic Information
| Provider Information | |||||||||
| NPI: | 1497190862 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HECKLE | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | REID | ||||||||
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| Mailing Information | |||||||||
| Address1: | 956 COURT AVE | ||||||||
| Address2: | ROOM H314 | ||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381032814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9014485814 | ||||||||
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| Practice Location | |||||||||
| Address1: | 910 MADISON AVE | ||||||||
| Address2: | SUITE 1031 | ||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381033403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9014485814 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/30/2013 | ||||||||
| LastUpdateDate: | 11/27/2017 | ||||||||
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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 | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207R00000X | MD0000054973 | TN | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.