1518666569 NPI number — MR. JASON MICHAEL MARREN

Table of content: MR. JASON MICHAEL MARREN (NPI 1518666569)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518666569 NPI number — MR. JASON MICHAEL MARREN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARREN
Provider First Name:
JASON
Provider Middle Name:
MICHAEL
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
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:
1518666569
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/28/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
520 S RALEIGH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARTINSBURG
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
25401-2642
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
240-527-4941
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
520 S RALEIGH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARTINSBURG
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25401-2642
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-262-9831
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/28/2023

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: 175T00000X , with the licence number:  23-911 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 23-911 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".