Provider Demographics
NPI:1417039801
Name:WAHLQUIST, MARC (MD)
Entity Type:Individual
Prefix:DR
First Name:MARC
Middle Name:
Last Name:WAHLQUIST
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 1:6480 HARRISON AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45247-7961
Mailing Address - Country:US
Mailing Address - Phone:513-354-3700
Mailing Address - Fax:513-699-1435
Practice Address - Street 1:538 OAK ST
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45219-2554
Practice Address - Country:US
Practice Address - Phone:513-354-3700
Practice Address - Fax:513-699-1435
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35084068207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2595071Medicaid
OHWA4155985Medicare PIN
OH2595071Medicaid