Provider Demographics
NPI:1083699227
Name:SHIE, MARVIN D III (MD)
Entity Type:Individual
Prefix:DR
First Name:MARVIN
Middle Name:D
Last Name:SHIE
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 74692
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44194-0002
Mailing Address - Country:US
Mailing Address - Phone:440-895-5021
Mailing Address - Fax:440-895-5050
Practice Address - Street 1:15644 MADISON AVENUE
Practice Address - Street 2:SUITE 107
Practice Address - City:LAKEWOOD
Practice Address - State:OH
Practice Address - Zip Code:44107-5622
Practice Address - Country:US
Practice Address - Phone:216-221-7400
Practice Address - Fax:216-221-7950
Is Sole Proprietor?:No
Enumeration Date:2005-12-09
Last Update Date:2010-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35035105S208600000X
OH35-035105208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0377999Medicaid
CA4511OtherRR MEDICARE GROUP
OH341318336OtherFEDERAL TAX ID
OHB96480Medicare UPIN
OH0475442Medicare PIN