Provider Demographics
NPI:1346466091
Name:MARINO, MICHELLE (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:
Last Name:MARINO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3526 VISTA AVE APT B
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63104-1006
Mailing Address - Country:US
Mailing Address - Phone:210-900-6243
Mailing Address - Fax:
Practice Address - Street 1:1465 S GRAND BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-1003
Practice Address - Country:US
Practice Address - Phone:314-678-3044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01062224A207L00000X
TXN3822207LP3000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP3000XAllopathic & Osteopathic PhysiciansAnesthesiologyPediatric Anesthesiology
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1346466091Medicaid