Provider Demographics
NPI:1417967712
Name:IMMERMAN, MARC (MD)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:
Last Name:IMMERMAN
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 1:1003 WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14901-1007
Mailing Address - Country:US
Mailing Address - Phone:607-732-5646
Mailing Address - Fax:607-732-0373
Practice Address - Street 1:1003 WALNUT ST
Practice Address - Street 2:
Practice Address - City:ELMIRA
Practice Address - State:NY
Practice Address - Zip Code:14901-1007
Practice Address - Country:US
Practice Address - Phone:607-732-5646
Practice Address - Fax:607-732-0373
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2018-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174214207P00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000915192004OtherBCBS
NY01144467Medicaid
NYRB4403Medicare PIN
NYE15681Medicare UPIN
NYDD6324Medicare ID - Type Unspecified
P00452843Medicare PIN