1629013966 NPI number — PETER R MARCELLUS MD

Table of content: PETER R MARCELLUS MD (NPI 1629013966)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629013966 NPI number — PETER R MARCELLUS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARCELLUS
Provider First Name:
PETER
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
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:
1629013966
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/12/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1150 STATE HIGHWAY 248
Provider Second Line Business Mailing Address:
STE, 202
Provider Business Mailing Address City Name:
BRANSON
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65616-3758
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-335-7000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1150 STATE HIGHWAY 248
Provider Second Line Business Practice Location Address:
STE, 202
Provider Business Practice Location Address City Name:
BRANSON
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65616-3758
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-335-7000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/19/2006

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: 207Q00000X , with the licence number:  R3E69 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 080110697 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 202071965 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1667 . This is a "COX HEALTH SYSTEMS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 8068 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: P00237019 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1107752 . This is a "HEALTHLINK" identifier . This identifiers is of the category "OTHER".




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