Provider Demographics
NPI:1619969961
Name:NELSON, MARIANNE (MD)
Entity Type:Individual
Prefix:
First Name:MARIANNE
Middle Name:
Last Name:NELSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARIANNE
Other - Middle Name:
Other - Last Name:PLASCAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 771923
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1923
Mailing Address - Country:US
Mailing Address - Phone:317-528-8000
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:420 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BROOK
Practice Address - State:IN
Practice Address - Zip Code:47922-8715
Practice Address - Country:US
Practice Address - Phone:219-275-2521
Practice Address - Fax:219-275-9342
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2021-12-01
Deactivation Date:2006-03-27
Deactivation Code:
Reactivation Date:2006-04-03
Provider Licenses
StateLicense IDTaxonomies
IN01033812207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
000001130557OtherANTHEM
IN100143000Medicaid
IND69604Medicare UPIN