Provider Demographics
NPI:1396836797
Name:FORSYTH, MARLIN M (PT)
Entity Type:Individual
Prefix:MR
First Name:MARLIN
Middle Name:M
Last Name:FORSYTH
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:425 MEDICAL DRIVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010
Mailing Address - Country:US
Mailing Address - Phone:801-292-5011
Mailing Address - Fax:801-292-8222
Practice Address - Street 1:425 MEDICAL DRIVE
Practice Address - Street 2:SUITE 104
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010
Practice Address - Country:US
Practice Address - Phone:801-292-5011
Practice Address - Fax:801-292-8222
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
UT107338-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT005700801Medicare ID - Type Unspecified