Provider Demographics
NPI:1437780335
Name:MARCELLUS MEDICAL GROUP PLLC
Entity Type:Organization
Organization Name:MARCELLUS MEDICAL GROUP PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KHATUNA
Authorized Official - Middle Name:N
Authorized Official - Last Name:STEPKOVITCH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:315-673-1529
Mailing Address - Street 1:1/2 ORANGE ST
Mailing Address - Street 2:
Mailing Address - City:MARCELLUS
Mailing Address - State:NY
Mailing Address - Zip Code:13108-1216
Mailing Address - Country:US
Mailing Address - Phone:317-673-1529
Mailing Address - Fax:315-673-2434
Practice Address - Street 1:1/2 ORANGE ST
Practice Address - Street 2:
Practice Address - City:MARCELLUS
Practice Address - State:NY
Practice Address - Zip Code:13108-1216
Practice Address - Country:US
Practice Address - Phone:317-673-1529
Practice Address - Fax:315-673-2434
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-29
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty