Basic Information
Provider Information | |||||||||
NPI: | 1013389931 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MARATHON HEALTH, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MARATHON HEALTH AT LANE | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 20 WINOOSKI FALLS WAY | ||||||||
Address2: | SUITE 400 | ||||||||
City: | WINOOSKI | ||||||||
State: | VT | ||||||||
PostalCode: | 054042228 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8028570400 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 4725 VILLAGE PLAZA LOOP | ||||||||
Address2: | SUITE 100, C/O LANE COUNTY EMPLOYEE HEALTH CENTER | ||||||||
City: | EUGENE | ||||||||
State: | OR | ||||||||
PostalCode: | 974016677 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8028570400 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/30/2015 | ||||||||
LastUpdateDate: | 10/30/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | FORD | ||||||||
AuthorizedOfficialFirstName: | JERRY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 8028570400 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | MARATHON HEALTH, INC. | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
No ID Information.