Provider Demographics
NPI:1558438671
Name:MARCHUK, JON BLAIR
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:BLAIR
Last Name:MARCHUK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2501 KEENAN DR
Mailing Address - Street 2:
Mailing Address - City:INTERNATIONAL FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56649-2181
Mailing Address - Country:US
Mailing Address - Phone:218-283-9431
Mailing Address - Fax:
Practice Address - Street 1:2501 KEENAN DR
Practice Address - Street 2:
Practice Address - City:INTERNATIONAL FALLS
Practice Address - State:MN
Practice Address - Zip Code:56649-2181
Practice Address - Country:US
Practice Address - Phone:218-283-9431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN38444208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
D50216Medicare UPIN