Provider Demographics
NPI:1932488608
Name:MYER, MARC JOSEPH (MD)
Entity Type:Individual
Prefix:DR
First Name:MARC
Middle Name:JOSEPH
Last Name:MYER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 833
Mailing Address - Street 2:
Mailing Address - City:LINDSTROM
Mailing Address - State:MN
Mailing Address - Zip Code:55045-0833
Mailing Address - Country:US
Mailing Address - Phone:612-393-1212
Mailing Address - Fax:651-400-3892
Practice Address - Street 1:12081 285TH ST
Practice Address - Street 2:
Practice Address - City:LINDSTROM
Practice Address - State:MN
Practice Address - Zip Code:55045-8084
Practice Address - Country:US
Practice Address - Phone:612-393-1212
Practice Address - Fax:651-400-3892
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-11
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN43740207Q00000X
MN61-22856207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty