Provider Demographics
NPI:1407809866
Name:MARSHALL, BRUCE
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:
Last Name:MARSHALL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6896 W SNOWVILLE RD
Mailing Address - Street 2:
Mailing Address - City:BRECKSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44141-3214
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4700 WATERS AVE
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31404-6220
Practice Address - Country:US
Practice Address - Phone:912-350-3849
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2007-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC51160207P00000X
GA51160207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAN362163OtherWELLCARE
GAG51160Medicaid
SCG651160Medicaid
GA10064673OtherAMERIGROUP
GAG51160Medicaid
GAP00042341Medicare PIN
GA93BDWDTMedicare PIN