Provider Demographics
NPI:1457365124
Name:KETCHERSID, MARIE KATHLEEN (MD)
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:KATHLEEN
Last Name:KETCHERSID
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 1:2232 WILBORN AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:VA
Mailing Address - Zip Code:24592-1662
Mailing Address - Country:US
Mailing Address - Phone:434-517-6180
Mailing Address - Fax:434-517-6179
Practice Address - Street 1:2232 WILBORN AVE
Practice Address - Street 2:
Practice Address - City:SOUTH BOSTON
Practice Address - State:VA
Practice Address - Zip Code:24592-1662
Practice Address - Country:US
Practice Address - Phone:434-517-6180
Practice Address - Fax:434-517-6179
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2011-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101054916207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G04732Medicare UPIN