Provider Demographics
NPI:1043236615
Name:PERSONS, MARJIE L (MD)
Entity Type:Individual
Prefix:
First Name:MARJIE
Middle Name:L
Last Name:PERSONS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24701 EUCLID AVE
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44117-1714
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11100 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106-1716
Practice Address - Country:US
Practice Address - Phone:216-844-7874
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2011-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-048167208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000503715OtherANTHEM
OH738083OtherBUCKEYE
OHP00091489OtherRAILROAD MEDICARE
OH0616239OtherBCMH
OH000000206730OtherUNISON
OH363908OtherWELLCARE
4007766OtherAETNA
OH0616239Medicaid
OHP00353693OtherRAILROAD MEDICARE
OHPE0535404Medicare PIN
000000503715OtherANTHEM
OH363908OtherWELLCARE