Provider Demographics
NPI:1790966810
Name:MARCUS WIGUTOW, M.D., INC.
Entity Type:Organization
Organization Name:MARCUS WIGUTOW, M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARCUS
Authorized Official - Middle Name:
Authorized Official - Last Name:WIGUTOW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:219-769-5900
Mailing Address - Street 1:9120 CONNECTICUT DR.
Mailing Address - Street 2:SUITE E
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-7172
Mailing Address - Country:US
Mailing Address - Phone:219-759-5900
Mailing Address - Fax:219-769-5987
Practice Address - Street 1:9120 CONNECTICUT DR
Practice Address - Street 2:SUITE E
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-7172
Practice Address - Country:US
Practice Address - Phone:219-769-5900
Practice Address - Fax:219-769-5987
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-16
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01022387B2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1320159050Medicaid
IL91106545OtherBLUE SHIELD
IN000000095335OtherBLUE SHIELD
03166600OtherMAGELLAN
137824OtherCOMPSYCH
IN476700Medicare PIN
IL91106545OtherBLUE SHIELD