Provider Demographics
NPI:1295061703
Name:HAYNES, MARCUS JOHNSON
Entity type:Individual
Prefix:DR
First Name:MARCUS
Middle Name:JOHNSON
Last Name:HAYNES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6397 LEE HWY
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-2564
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:705 TOWN BLVD NE STE S550
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:GA
Practice Address - Zip Code:30319-7216
Practice Address - Country:US
Practice Address - Phone:404-869-1912
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-19
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1192799225100000X
GAPT013707225100000X
TN8470225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8L22453Medicare PIN