Provider Demographics
NPI:1588652812
Name:FLICKINGER, MARC WILLIAM (MD)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:WILLIAM
Last Name:FLICKINGER
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:PO BOX 75268
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21275-5268
Mailing Address - Country:US
Mailing Address - Phone:434-654-7794
Mailing Address - Fax:434-654-7752
Practice Address - Street 1:500 MARTHA JEFFERSON DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22911-4668
Practice Address - Country:US
Practice Address - Phone:434-654-7580
Practice Address - Fax:434-654-7582
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2015-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101242318207Q00000X, 207QH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAP01548324Medicare PIN
H37806Medicare UPIN
VAVV9785BMedicare PIN
VA2185374OtherCIGNA
VA7145258OtherAETNA
VA820580OtherSOUTHERN HEALTH
VA302011OtherANTHEM
VA1588652812Medicaid
VA017270C96Medicare PIN