Provider Demographics
NPI:1669772505
Name:MARATHON MEDICAL CLINIC, P.C.
Entity type:Organization
Organization Name:MARATHON MEDICAL CLINIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ABNER
Authorized Official - Middle Name:J
Authorized Official - Last Name:ESPINOSA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:810-793-7550
Mailing Address - Street 1:PO BOX 7
Mailing Address - Street 2:
Mailing Address - City:COLUMBIAVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48421-0007
Mailing Address - Country:US
Mailing Address - Phone:810-793-7550
Mailing Address - Fax:810-793-7962
Practice Address - Street 1:4526 PINE ST
Practice Address - Street 2:
Practice Address - City:COLUMBIAVILLE
Practice Address - State:MI
Practice Address - Zip Code:48421-8920
Practice Address - Country:US
Practice Address - Phone:810-793-7550
Practice Address - Fax:810-793-7962
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-26
Last Update Date:2010-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301039120207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2097133Medicaid
MI2097133Medicaid