Provider Demographics
NPI:1972534261
Name:WILLAGE, MARC B (MD)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:B
Last Name:WILLAGE
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 189
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:IN
Mailing Address - Zip Code:47250-0189
Mailing Address - Country:US
Mailing Address - Phone:812-427-2911
Mailing Address - Fax:812-427-9056
Practice Address - Street 1:213 W MAIN ST
Practice Address - Street 2:
Practice Address - City:VEVAY
Practice Address - State:IN
Practice Address - Zip Code:47043-1127
Practice Address - Country:US
Practice Address - Phone:812-427-2911
Practice Address - Fax:812-427-9056
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2013-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01037094207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN412890POtherSIHO
KY64876097Medicaid
080137279OtherMEDICARE RAILROAD
IN100110720AMedicaid
IN000000042208OtherANTHEM BCBS
4386715OtherAETNA
4386715OtherAETNA
IN000000042208OtherANTHEM BCBS
080137279OtherMEDICARE RAILROAD
D10631Medicare UPIN