Provider Demographics
NPI:1396852794
Name:MARSH, JEFFREY L (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:L
Last Name:MARSH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JEFFREY
Other - Middle Name:L
Other - Last Name:MARSH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:621 S NEW BALLAS RD
Mailing Address - Street 2:SUITE 260-A
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8232
Mailing Address - Country:US
Mailing Address - Phone:314-251-4772
Mailing Address - Fax:314-251-5772
Practice Address - Street 1:621 S NEW BALLAS RD
Practice Address - Street 2:SUITE 260-A
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8232
Practice Address - Country:US
Practice Address - Phone:314-251-4772
Practice Address - Fax:314-251-5772
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2011-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR79982086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200508315Medicaid
MO001014821Medicare ID - Type Unspecified
MO200508315Medicaid