Basic Information
| Provider Information | |||||||||
| NPI: | 1053411447 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NATHANIEL TRAVIS MARVEL, JR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 643680 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452643680 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5138912813 | ||||||||
| FaxNumber: | 5137931032 | ||||||||
| Practice Location | |||||||||
| Address1: | 143 LAKEVIEW CT. | ||||||||
| Address2: | |||||||||
| City: | LOVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135351064 | ||||||||
| FaxNumber: | 5137748612 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2006 | ||||||||
| LastUpdateDate: | 11/30/2007 | ||||||||
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| AuthorizedOfficialLastName: | MARVEL | ||||||||
| AuthorizedOfficialFirstName: | NATHANIEL | ||||||||
| AuthorizedOfficialMiddleName: | TRAVIS | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5135351064 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0805X | 35-051342 | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Geriatric Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | DF0430 | 01 | OH | RR MEDICARE | OTHER |