Basic Information
| Provider Information | |||||||||
| NPI: | 1144225558 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARBURG | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | CHARLES | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4402 SHIPYARD BLVD | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284036161 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104521400 | ||||||||
| FaxNumber: | 9103321072 | ||||||||
| Practice Location | |||||||||
| Address1: | 4402 SHIPYARD BLVD | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284036161 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104521400 | ||||||||
| FaxNumber: | 9103321072 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2005 | ||||||||
| LastUpdateDate: | 11/16/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 27706 | NC | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | 208D00000X | 27706 | NC | N | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 53962 | 01 | NC | BCBS | OTHER | 27492 | 01 | NC | MEDCOST | OTHER | 110127021 | 01 | NC | RAILROAD MEDICARE | OTHER | 01-28858 | 01 | NC | UNITED HEALTHCARE | OTHER |