Provider Demographics
NPI:1205837952
Name:MARION, MALCOLM L III (MD)
Entity Type:Individual
Prefix:
First Name:MALCOLM
Middle Name:L
Last Name:MARION
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-384-7840
Mailing Address - Fax:700-438-4783
Practice Address - Street 1:1435 EBENEZER RD
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-2338
Practice Address - Country:US
Practice Address - Phone:803-328-3828
Practice Address - Fax:803-328-3879
Is Sole Proprietor?:No
Enumeration Date:2005-08-03
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SC8859207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC088595Medicaid
SC088595Medicaid
NCD182378444Medicare PIN
AM7425312OtherDEA#