1902893183 NPI number — DR. KENNETH ARMISTICE MARRIOTT III M.D.

Table of content: DR. KENNETH ARMISTICE MARRIOTT III M.D. (NPI 1902893183)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902893183 NPI number — DR. KENNETH ARMISTICE MARRIOTT III M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARRIOTT
Provider First Name:
KENNETH
Provider Middle Name:
ARMISTICE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
III
Provider Credential Text:
M.D.
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:
1902893183
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/09/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
215 W MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEBANON
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62254-1533
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-256-7595
Provider Business Mailing Address Fax Number:
618-256-7575

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
375TH MEDICAL GROUP
Provider Second Line Business Practice Location Address:
310 W LOSEY
Provider Business Practice Location Address City Name:
SCOTT AIR FORCE BASE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62225
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-256-7595
Provider Business Practice Location Address Fax Number:
618-256-7575
Provider Enumeration Date:
10/03/2005

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: 207P00000X , with the licence number:  0101236229 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207P00000X , with the licence number: N8121 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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