Provider Demographics
NPI:1245207950
Name:FARRAYE, MARC J (MD)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:J
Last Name:FARRAYE
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 1:218 SOPHIA TER
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32095-6812
Mailing Address - Country:US
Mailing Address - Phone:904-662-6661
Mailing Address - Fax:
Practice Address - Street 1:218 SOPHIA TER
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32095-6812
Practice Address - Country:US
Practice Address - Phone:904-662-6661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA049607207P00000X
FLME84425207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000905286CMedicaid
FL264217400Medicaid
GA00905286BMedicaid
FL13736OtherBCBS
GA93BDQPKMedicare ID - Type UnspecifiedMEDICARE
FL13736BMedicare PIN
P00258713Medicare PIN
GA00905286BMedicaid