Provider Demographics
NPI:1437333630
Name:MARR, BRENDAN M (MD)
Entity Type:Individual
Prefix:
First Name:BRENDAN
Middle Name:M
Last Name:MARR
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 1:131 MEDICAL PARK RD STE 303
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-8525
Mailing Address - Country:US
Mailing Address - Phone:704-660-4584
Mailing Address - Fax:704-660-4967
Practice Address - Street 1:131 MEDICAL PARK RD STE 303
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-8525
Practice Address - Country:US
Practice Address - Phone:704-660-4584
Practice Address - Fax:704-660-4967
Is Sole Proprietor?:No
Enumeration Date:2007-12-24
Last Update Date:2019-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD449620208600000X
NC2018-02219208600000X
MI4301088127208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102763029Medicaid
OH0052775Medicaid
317462Medicare PIN
PA1027630290003Medicaid