Provider Demographics
NPI:1790755452
Name:MARSH, ELLIS EUGENE (MD)
Entity Type:Individual
Prefix:
First Name:ELLIS
Middle Name:EUGENE
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 1:303 BENNER PIKE
Mailing Address - Street 2:
Mailing Address - City:STATE COLLEGE
Mailing Address - State:PA
Mailing Address - Zip Code:16801-7304
Mailing Address - Country:US
Mailing Address - Phone:814-272-4403
Mailing Address - Fax:814-272-4440
Practice Address - Street 1:303 BENNER PIKE
Practice Address - Street 2:
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16801-7304
Practice Address - Country:US
Practice Address - Phone:814-272-4403
Practice Address - Fax:814-272-4440
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4419252084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000086091Medicaid
ALBM0894647OtherDEA
ALBM0894647OtherDEA
AL000086091Medicaid