Provider Demographics
NPI:1144236159
Name:LARSEN, MARC DEVRIES (MD)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:DEVRIES
Last Name:LARSEN
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 78009
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63178
Mailing Address - Country:US
Mailing Address - Phone:616-975-9824
Mailing Address - Fax:616-975-9827
Practice Address - Street 1:4401 WORNALL RD
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64111
Practice Address - Country:US
Practice Address - Phone:816-932-2047
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2008-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006010971207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
37548019OtherBCBS
P00393448OtherRAILROAD MEDICARE
37548019OtherBCBS
J55E905Medicare PIN