Provider Demographics
NPI:1780683391
Name:HAY, MARSHALL BLAKE (MD)
Entity type:Individual
Prefix:
First Name:MARSHALL
Middle Name:BLAKE
Last Name:HAY
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 1:611 W. PARK ST.
Mailing Address - Street 2:BWPC
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-2500
Mailing Address - Country:US
Mailing Address - Phone:217-383-6792
Mailing Address - Fax:
Practice Address - Street 1:611 W. PARK ST.
Practice Address - Street 2:RADIOLOGY
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61801-2530
Practice Address - Country:US
Practice Address - Phone:217-383-3270
Practice Address - Fax:217-383-4116
Is Sole Proprietor?:No
Enumeration Date:2005-07-15
Last Update Date:2016-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010615202085R0202X
IL0361308482085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104363730Medicaid
MIMH061520OtherBC/BS INDIVIDUAL PIN NO
MI300128669OtherRR MDCR INDIVIDUAL PIN NO
MI11278282OtherCAQH
MIM72490008Medicare PIN
G78082Medicare UPIN