Provider Demographics
NPI:1720063621
Name:O'MARY, MARCUS WADE (DC)
Entity Type:Individual
Prefix:
First Name:MARCUS
Middle Name:WADE
Last Name:O'MARY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 22ND AVE E
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:AL
Mailing Address - Zip Code:35501-4023
Mailing Address - Country:US
Mailing Address - Phone:205-384-5358
Mailing Address - Fax:205-384-5360
Practice Address - Street 1:301 22ND AVE E
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:AL
Practice Address - Zip Code:35501-4023
Practice Address - Country:US
Practice Address - Phone:205-384-5358
Practice Address - Fax:205-384-5360
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-13
Last Update Date:2013-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1152111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051523516OtherBCBS PROVIDER NUMBER
ALT68519Medicare UPIN
AL051523516OtherBCBS PROVIDER NUMBER
AL051523516OMAMedicare PIN