Provider Demographics
NPI:1649224650
Name:PRUITT, MARION EUGENE (MD)
Entity Type:Individual
Prefix:DR
First Name:MARION
Middle Name:EUGENE
Last Name:PRUITT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:M
Other - Middle Name:EUGENE
Other - Last Name:PRUITT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:DEPT OF INTERNAL MEDICINE
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-805-6850
Mailing Address - Fax:414-805-7967
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:DEPT OF INTERNAL MEDICINE
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-805-6850
Practice Address - Fax:414-805-7967
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI23496207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
007006261SOtherHUMANA
WI1649224650Medicaid
WI002N73601Medicare PIN
WI1649224650Medicaid