Provider Demographics
NPI:1760458277
Name:MARSH, MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:MARSH
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 1:9170 DOE HILL RD
Mailing Address - Street 2:
Mailing Address - City:PORT REPUBLIC
Mailing Address - State:VA
Mailing Address - Zip Code:24471-2119
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15 KILLDEER LN
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:VA
Practice Address - Zip Code:22821-9745
Practice Address - Country:US
Practice Address - Phone:540-879-2585
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2011-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101-35025207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005622999Medicaid
VAB06614Medicare UPIN
VA017922C18Medicare PIN
080005593Medicare PIN