Provider Demographics
NPI:1942740675
Name:MARATHON HEALTH, LLC
Entity Type:Organization
Organization Name:MARATHON HEALTH, LLC
Other - Org Name:MARATHON HEALTH AT BREVARD NORTH
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:FORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:802-857-0400
Mailing Address - Street 1:20 WINOOSKI FALLS WAY
Mailing Address - Street 2:STE. 400
Mailing Address - City:WINOOSKI
Mailing Address - State:VT
Mailing Address - Zip Code:05404-2228
Mailing Address - Country:US
Mailing Address - Phone:802-857-0400
Mailing Address - Fax:
Practice Address - Street 1:1505 KNOX MCRAE DRIVE
Practice Address - Street 2:C/O BREVARD WELLCARE- NORTH
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32780
Practice Address - Country:US
Practice Address - Phone:802-857-0400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARATHON HEALTH, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-02-28
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty