Provider Demographics
NPI:1134182843
Name:MARRIOTT, TAMI SUE (MD)
Entity type:Individual
Prefix:
First Name:TAMI
Middle Name:SUE
Last Name:MARRIOTT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:TAMI
Other - Middle Name:SUE
Other - Last Name:GERSTNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2100 POWELL ST
Mailing Address - Street 2:STE 900
Mailing Address - City:EMERYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94608-1844
Mailing Address - Country:US
Mailing Address - Phone:510-851-7423
Mailing Address - Fax:510-879-9120
Practice Address - Street 1:2700 NW STEWART PKWY
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-1281
Practice Address - Country:US
Practice Address - Phone:541-677-4333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2017-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD27684207P00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH311397603026Medicaid
OH2105886Medicaid
OR214021Medicaid
OH000000038219OtherANTHEM
OHGE0858911Medicare PIN
OH000000038219OtherANTHEM
OH311397603026Medicaid
ORR140876Medicare PIN
OHG80429Medicare UPIN
OH2105886Medicaid