Provider Demographics
NPI:1255350831
Name:SWANSON, MARC A (MD)
Entity type:Individual
Prefix:
First Name:MARC
Middle Name:A
Last Name:SWANSON
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 1:3426 W RIDGE RD SW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24014-4224
Mailing Address - Country:US
Mailing Address - Phone:540-494-9378
Mailing Address - Fax:
Practice Address - Street 1:100 KNOTBREAK RD
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:VA
Practice Address - Zip Code:24153-5414
Practice Address - Country:US
Practice Address - Phone:540-444-5670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2024-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101046486207LP2900X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010376301Medicaid
A72712Medicare UPIN
011918L84Medicare PIN
VA010376301Medicaid