Provider Demographics
NPI:1942293907
Name:MARMOLYA, GARY (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:
Last Name:MARMOLYA
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:PO BOX 567
Mailing Address - Street 2:
Mailing Address - City:CHAGRIN FALLS
Mailing Address - State:OH
Mailing Address - Zip Code:44022-0567
Mailing Address - Country:US
Mailing Address - Phone:216-464-5160
Mailing Address - Fax:216-464-5982
Practice Address - Street 1:18697 BAGLEY RD
Practice Address - Street 2:RADIOLOGY DEPARTMENT
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44130-3417
Practice Address - Country:US
Practice Address - Phone:440-816-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-25
Last Update Date:2008-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350415622085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHP00412503OtherRAILROAD MEDICARE
OH363808OtherWELLCARE
OH733052OtherBUCKEYE
OH4261908OtherAETNA
OH000000221317OtherUNISON
OH00000516221OtherANTHEM
OH0750763Medicaid
OH4261908OtherAETNA
OHMA4065866Medicare ID - Type Unspecified
OHE29591Medicare UPIN