Basic Information
| Provider Information | |||||||||
| NPI: | 1053394544 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARSHALL | ||||||||
| FirstName: | DEBRA | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GOSSER | ||||||||
| OtherFirstName: | DEBRA | ||||||||
| OtherMiddleName: | MARSHALL | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 950202 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402950202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5029696552 | ||||||||
| FaxNumber: | 5029693799 | ||||||||
| Practice Location | |||||||||
| Address1: | 825 BARRET AVE | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402041743 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025407200 | ||||||||
| FaxNumber: | 5025407207 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2005 | ||||||||
| LastUpdateDate: | 03/26/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 32280 | KY | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2851803000 | 01 | PAD - NCMA | OTHER | 64322803 | 05 | KY | MEDICAID | 085492 | 01 | SIHO - NCMA | OTHER | 50015283 | 01 | PASSPORT - NCMA | OTHER | P00410727 | 01 | KY | RAILROAD MEDICARE | OTHER | 000000514956 | 01 | KY | ANTHEM - NCMA | OTHER |