Provider Demographics
NPI:1689761108
Name:OH, MARILOU (PA-C)
Entity Type:Individual
Prefix:MS
First Name:MARILOU
Middle Name:
Last Name:OH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:MARILOU
Other - Middle Name:
Other - Last Name:OH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1 LONG WHARF DR STE 212
Mailing Address - Street 2:ADVANCED DIAGNOSTIC PAIN TREATMENT CENTERS, PC
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-5593
Mailing Address - Country:US
Mailing Address - Phone:203-624-4208
Mailing Address - Fax:203-624-4301
Practice Address - Street 1:1 LONG WHARF DR STE 212
Practice Address - Street 2:ADVANCED DIAGNOSTIC PAIN TREATMENT CENTERS, PC
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-5593
Practice Address - Country:US
Practice Address - Phone:203-624-4208
Practice Address - Fax:203-624-4301
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001257363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT970001192Medicare ID - Type Unspecified