Provider Demographics
NPI:1134188170
Name:TERRANELLA, MARILYN (MD)
Entity type:Individual
Prefix:
First Name:MARILYN
Middle Name:
Last Name:TERRANELLA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 JOHN ST
Mailing Address - Street 2:SUITE M020
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007-5341
Mailing Address - Country:US
Mailing Address - Phone:269-657-4407
Mailing Address - Fax:269-657-2550
Practice Address - Street 1:601 JOHN ST
Practice Address - Street 2:SUITE M020
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-5341
Practice Address - Country:US
Practice Address - Phone:269-657-4407
Practice Address - Fax:269-657-2550
Is Sole Proprietor?:No
Enumeration Date:2006-03-20
Last Update Date:2014-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301037765207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1134188170Medicaid
MI1104840529OtherBCBSM - BRONSON
MI4186831Medicaid
1103958601OtherBCBS
1103958601OtherBCBS
MI1134188170Medicaid
MI4186831Medicaid