Provider Demographics
NPI:1780817544
Name:BAME, MARILYN SUSAN (RD, LD, CDE)
Entity Type:Individual
Prefix:MRS
First Name:MARILYN
Middle Name:SUSAN
Last Name:BAME
Suffix:
Gender:F
Credentials:RD, LD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5871 MONCLOVA RD
Mailing Address - Street 2:DIABETES CARE CENTER @ ST. LUKE'S HOSPITAL
Mailing Address - City:MAUMEE
Mailing Address - State:OH
Mailing Address - Zip Code:43537-1839
Mailing Address - Country:US
Mailing Address - Phone:419-897-8391
Mailing Address - Fax:419-887-8789
Practice Address - Street 1:5871 MONCLOVA RD
Practice Address - Street 2:DIABETES CARE CENTER @ ST. LUKE'S HOSPITAL
Practice Address - City:MAUMEE
Practice Address - State:OH
Practice Address - Zip Code:43537-1839
Practice Address - Country:US
Practice Address - Phone:419-897-8391
Practice Address - Fax:419-887-8789
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-27
Last Update Date:2011-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
383926133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered