1144274275 NPI number — DON A MARSHALL JR. MD

Table of content: DON A MARSHALL JR. MD (NPI 1144274275)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144274275 NPI number — DON A MARSHALL JR. MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARSHALL
Provider First Name:
DON
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
JR.
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1144274275
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/03/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3010 E STATE BLVD
Provider Second Line Business Mailing Address:
SUTIE 100
Provider Business Mailing Address City Name:
FORT WAYNE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46805-4700
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
260-471-0632
Provider Business Mailing Address Fax Number:
260-471-3451

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3010 E STATE BLVD
Provider Second Line Business Practice Location Address:
SUTIE 100
Provider Business Practice Location Address City Name:
FORT WAYNE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46805-4700
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-471-0632
Provider Business Practice Location Address Fax Number:
260-471-3451
Provider Enumeration Date:
05/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  01038606A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2084P0802X , with the licence number: 01038606A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084A0401X , with the licence number: 01038606A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100082250B , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 93110 . This is a "ANTHEM HIP" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 10082250B . This is a "PCCM" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 119094 . This is a "COMPSYCH" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 000000006472 . This is a "MPLAN & 3 RIVERS" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 000000093110 . This is a "ANTHEM BCBS" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 0944554 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3382 . This is a "PHP" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 063909 . This is a "VALUE OPT" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 01008583 . This is a "HEALTHPLUS" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 01652800 . This is a "MEGELLAN" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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