Basic Information
| Provider Information | |||||||||
| NPI: | 1184711228 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARKS | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | EDWARD | ||||||||
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| Credential: | M.D., P.H.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 AFFLINK PL | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | TUSCALOOSA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 354062289 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2053669740 | ||||||||
| FaxNumber: | 2053449992 | ||||||||
| Practice Location | |||||||||
| Address1: | 171 TOWN CENTER DR | ||||||||
| Address2: | SUITE MPS-6 | ||||||||
| City: | ANNISTON | ||||||||
| State: | AL | ||||||||
| PostalCode: | 362054101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2568473369 | ||||||||
| FaxNumber: | 2568473469 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2006 | ||||||||
| LastUpdateDate: | 06/14/2012 | ||||||||
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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 | 2085R0001X | 14449 | AL | Y | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | 136417 | 05 | AL | MEDICAID |