Provider Demographics
NPI:1073652525
Name:PHILIP M MARDEN MD SC
Entity Type:Organization
Organization Name:PHILIP M MARDEN MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:M
Authorized Official - Last Name:MARDEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:262-567-0366
Mailing Address - Street 1:123 HOSPITAL DRIVE
Mailing Address - Street 2:SUITE 212
Mailing Address - City:WATERTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53098-3336
Mailing Address - Country:US
Mailing Address - Phone:920-261-3898
Mailing Address - Fax:262-567-0368
Practice Address - Street 1:123 HOSPITAL DRIVE
Practice Address - Street 2:SUITE 212
Practice Address - City:WATERTOWN
Practice Address - State:WI
Practice Address - Zip Code:53098-3336
Practice Address - Country:US
Practice Address - Phone:920-261-3898
Practice Address - Fax:262-567-0368
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14664207KA0200X, 207Q00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergyGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI14664OtherST OF WIS MEDICAL LICENSE
4308968OtherAETNA
WI31212300Medicaid
718112OtherMANAGED HEALTH SERVICES
1200110OtherUNITED HEALTHCARE
12659OtherDEAN HEALTH PLAN
112760524654OtherHUMANA
MARDENPHIOtherMERCYCARE HEALTH PLANS
W003437OtherCHAMPUS
AS68366510001OtherCIGNA
1000283OtherPHYSICIANS PLUS INSURANCE
213688OtherONE HEALTH PLAN
52D0388538OtherCLIA CERTIFICATE
WI14664OtherST OF WIS MEDICAL LICENSE
52D0388538OtherCLIA CERTIFICATE
W003437OtherCHAMPUS
4308968OtherAETNA
718112OtherMANAGED HEALTH SERVICES