Provider Demographics
NPI:1114906898
Name:MARKS, MICHAEL ALAN (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ALAN
Last Name:MARKS
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:PO BOX 3176
Mailing Address - Street 2:
Mailing Address - City:WEST SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42564-3176
Mailing Address - Country:US
Mailing Address - Phone:606-678-9105
Mailing Address - Fax:606-678-2296
Practice Address - Street 1:305 LANGDON ST
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42503-2750
Practice Address - Country:US
Practice Address - Phone:606-679-7441
Practice Address - Fax:606-678-9919
Is Sole Proprietor?:No
Enumeration Date:2006-01-11
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN312702085R0202X
KY359012085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3837361Medicaid
KY00280042Medicare PIN
KYP00603616Medicare PIN
TN3837361Medicare ID - Type Unspecified
KY0684414Medicare PIN
TN3837361Medicaid
KY00151031Medicare PIN
KY00503007Medicare PIN