Provider Demographics
NPI:1043294416
Name:MARSHALL, KENNETH ALAN (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:ALAN
Last Name:MARSHALL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 JACKSON PIKE
Mailing Address - Street 2:
Mailing Address - City:GALLIPOLIS
Mailing Address - State:OH
Mailing Address - Zip Code:45631-1560
Mailing Address - Country:US
Mailing Address - Phone:740-589-3100
Mailing Address - Fax:740-589-3123
Practice Address - Street 1:2131 E STATE ST
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:OH
Practice Address - Zip Code:45701-2138
Practice Address - Country:US
Practice Address - Phone:740-589-3100
Practice Address - Fax:740-589-3123
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCMD23820207L00000X
OH35051637207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC238200Medicaid
OH0072891Medicaid
WV3810027285Medicaid
SCGP2991Medicaid
SC6879Medicare PIN
SCGP2991Medicaid
OH0072891Medicaid
SC238200Medicaid
SCAA01336877Medicare PIN
OH140880Medicare PIN
SC6877Medicare PIN
SC6878Medicare PIN