Provider Demographics
NPI:1073659546
Name:MARDEN, PHILIP M (MD)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:M
Last Name:MARDEN
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 1:340 SUMMIT AVENUE
Mailing Address - Street 2:
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-3747
Mailing Address - Country:US
Mailing Address - Phone:262-567-0366
Mailing Address - Fax:262-567-0368
Practice Address - Street 1:340 SUMMIT AVENUE
Practice Address - Street 2:
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066-3747
Practice Address - Country:US
Practice Address - Phone:262-567-0366
Practice Address - Fax:262-567-0368
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2012-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14664207KA0200X, 207Q00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
1000283OtherPHYSICIANS PLUS INSURANCE
1200110OtherUNITED HEALTHCARE
AS68366510001OtherCIGNA
718112OtherMANAGED HEALTH SERVICES
52D0388538OtherCLIA CERTIFICATE
12659OtherDEAN HEALTH PLAN
WI14664OtherST OF WIS MEDICAL LICENSE
213688OtherONE HEALTH PLAN
WI31212300Medicaid
4308968OtherAETNA
MARDENPHIOtherMERCYCARE HEALTH PLANS
112760524654OtherHUMANA
W003437OtherCHAMPUS
MARDENPHIOtherMERCYCARE HEALTH PLANS
WI31212300Medicaid