Provider Demographics
NPI:1245651207
Name:MARIETTA MEDICAL LTD
Entity type:Organization
Organization Name:MARIETTA MEDICAL LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:D
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:740-236-1232
Mailing Address - Street 1:101 PUTNAM ST
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:OH
Mailing Address - Zip Code:45750-2924
Mailing Address - Country:US
Mailing Address - Phone:740-236-1232
Mailing Address - Fax:740-236-9191
Practice Address - Street 1:101 PUTNAM ST
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:OH
Practice Address - Zip Code:45750-2924
Practice Address - Country:US
Practice Address - Phone:740-236-1232
Practice Address - Fax:740-236-9191
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-18
Last Update Date:2013-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV14185207R00000X
OH35.063586207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty