Provider Demographics
NPI:1144236373
Name:DI BIASE, MARCO JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARCO
Middle Name:JOHN
Last Name:DI BIASE
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 1:4983 APPIAN WAY
Mailing Address - Street 2:
Mailing Address - City:BERRIEN SPRINGS
Mailing Address - State:MI
Mailing Address - Zip Code:49103-9558
Mailing Address - Country:US
Mailing Address - Phone:269-473-3195
Mailing Address - Fax:
Practice Address - Street 1:4983 APPIAN WAY
Practice Address - Street 2:
Practice Address - City:BERRIEN SPRINGS
Practice Address - State:MI
Practice Address - Zip Code:49103-9558
Practice Address - Country:US
Practice Address - Phone:269-473-3195
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2015-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI14270162085R0202X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OD66025Medicare ID - Type Unspecified
A77827Medicare UPIN