Provider Demographics
NPI:1225332315
Name:MARION OCCUPATIONAL MEDICINE LLC
Entity Type:Organization
Organization Name:MARION OCCUPATIONAL MEDICINE LLC
Other - Org Name:MARION PRIMARY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GARDNER
Authorized Official - Middle Name:
Authorized Official - Last Name:BARTRUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-664-9000
Mailing Address - Street 1:1614 N BALDWIN AVE
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46952-1437
Mailing Address - Country:US
Mailing Address - Phone:765-664-9000
Mailing Address - Fax:
Practice Address - Street 1:1614 N BALDWIN AVE
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46952-1437
Practice Address - Country:US
Practice Address - Phone:765-664-9000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-04
Last Update Date:2015-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201015960Medicaid
IN201015960Medicaid