Provider Demographics
NPI:1336295443
Name:MARVIN L WELLS DO PC
Entity Type:Organization
Organization Name:MARVIN L WELLS DO PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:WELLS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:313-563-3332
Mailing Address - Street 1:300 ROCK RUN RD
Mailing Address - Street 2:
Mailing Address - City:FRIENDLY
Mailing Address - State:WV
Mailing Address - Zip Code:26146
Mailing Address - Country:US
Mailing Address - Phone:313-563-3332
Mailing Address - Fax:313-563-3342
Practice Address - Street 1:300 ROCK RUN RD
Practice Address - Street 2:
Practice Address - City:FRIENDLY
Practice Address - State:WV
Practice Address - Zip Code:26146
Practice Address - Country:US
Practice Address - Phone:313-563-3332
Practice Address - Fax:313-563-3342
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2010-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MICE8407OtherRR MEDICARE
MI110F312140OtherBLUE SHIELD
MICE8407OtherRR MEDICARE