Provider Demographics
NPI:1295840114
Name:HAAS, MARJORIE (MD)
Entity type:Individual
Prefix:
First Name:MARJORIE
Middle Name:
Last Name:HAAS
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 1:234 VILLAGE PARK DR
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:OH
Mailing Address - Zip Code:45036-7709
Mailing Address - Country:US
Mailing Address - Phone:513-310-8288
Mailing Address - Fax:
Practice Address - Street 1:130 KATE IRELAND DR
Practice Address - Street 2:
Practice Address - City:HYDEN
Practice Address - State:KY
Practice Address - Zip Code:41749-9071
Practice Address - Country:US
Practice Address - Phone:606-672-2341
Practice Address - Fax:606-672-5254
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY49078208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0856453Medicaid
OH000000336825OtherANTHEM BC/BS
OHHA4119481OtherMEDICARE RAILROAD
OHHA4119481Medicare ID - Type Unspecified
OH6234102OtherHUMANA
OH1205103OtherUHC
OH0C02761OtherNATIONWIDE
OH5058027OtherAETNA
OHH97094Medicare UPIN