Provider Demographics
NPI:1013922699
Name:MARSHES MEDICAL DIAGNOSTIC CLINIC, PC
Entity Type:Organization
Organization Name:MARSHES MEDICAL DIAGNOSTIC CLINIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SEC/TREAS
Authorized Official - Prefix:MS
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:PAGE
Authorized Official - Last Name:CALLAHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-264-6133
Mailing Address - Street 1:2705 WILDWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31520-4346
Mailing Address - Country:US
Mailing Address - Phone:912-264-6133
Mailing Address - Fax:912-267-1415
Practice Address - Street 1:2705 WILDWOOD DR
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520-4346
Practice Address - Country:US
Practice Address - Phone:912-264-6133
Practice Address - Fax:912-267-1415
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2009-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GACL1232OtherRAILROAD MEDICARE
GAGRP 1465OtherCAHABA MEDICARE