Provider Demographics
NPI:1881600641
Name:MARILYN'S MEDICAL FREEDOM, INC.
Entity type:Organization
Organization Name:MARILYN'S MEDICAL FREEDOM, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:M
Authorized Official - Last Name:FOX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-534-9713
Mailing Address - Street 1:4860 OLD MAYFIELD RD
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42003-9074
Mailing Address - Country:US
Mailing Address - Phone:270-534-9713
Mailing Address - Fax:270-554-4643
Practice Address - Street 1:4860 OLD MAYFIELD RD
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-9074
Practice Address - Country:US
Practice Address - Phone:270-534-9713
Practice Address - Fax:270-554-4643
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-01
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332BC3200X
KY332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000385287OtherANTHEM BCBS
KY45003878Medicaid
KY90012808Medicaid
IL=========001Medicaid
IL=========001Medicaid