Provider Demographics
NPI:1710462098
Name:NEWMAN, MARVA ANN
Entity Type:Individual
Prefix:
First Name:MARVA
Middle Name:ANN
Last Name:NEWMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2545 S 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROADVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60155-4808
Mailing Address - Country:US
Mailing Address - Phone:708-533-0234
Mailing Address - Fax:
Practice Address - Street 1:2545 S 10TH AVE
Practice Address - Street 2:
Practice Address - City:BROADVIEW
Practice Address - State:IL
Practice Address - Zip Code:60155-4808
Practice Address - Country:US
Practice Address - Phone:708-533-0234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-02
Last Update Date:2018-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$Medicaid