Provider Demographics
NPI:1407852353
Name:MARILLEY, MARK D (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:D
Last Name:MARILLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 SE HOSPITAL AVE
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34994-2346
Mailing Address - Country:US
Mailing Address - Phone:727-287-5200
Mailing Address - Fax:
Practice Address - Street 1:200 SE HOSPITAL AVE
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-2346
Practice Address - Country:US
Practice Address - Phone:772-287-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-24
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV21764207RG0100X
FLME157995207RG0100X
PAMD425171207RG0100X
ORMD192722207RG0100X
NC200700105207RG0100X
CODR.0067585207RG0100X
GA350085209207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2521248Medicaid
PA1011688500001Medicaid
NC144T9OtherBCBSNC
WV3810001403Medicaid
NC5906555Medicaid
WV3810001403Medicaid
NCNC0357AMedicare PIN
G62859Medicare UPIN
OHMA4147654Medicare ID - Type Unspecified