Provider Demographics
NPI:1558352559
Name:EIDENBERG, MARSHALL EDWARD (DO)
Entity Type:Individual
Prefix:
First Name:MARSHALL
Middle Name:EDWARD
Last Name:EIDENBERG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2220 CANTERBURY DR
Mailing Address - Street 2:
Mailing Address - City:HAYS
Mailing Address - State:KS
Mailing Address - Zip Code:67601-2370
Mailing Address - Country:US
Mailing Address - Phone:785-623-5555
Mailing Address - Fax:
Practice Address - Street 1:2220 CANTERBURY DR
Practice Address - Street 2:
Practice Address - City:HAYS
Practice Address - State:KS
Practice Address - Zip Code:67601-2370
Practice Address - Country:US
Practice Address - Phone:785-623-5555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2016-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS05-32944207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200548360AMedicaid
PAI07883Medicare UPIN
KS1100990004Medicare PIN