Basic Information
| Provider Information | |||||||||
| NPI: | 1336102847 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MA | ||||||||
| FirstName: | MARCUS | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3355 GLENDALE AVE FL 3 | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436142426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193833888 | ||||||||
| FaxNumber: | 4193832860 | ||||||||
| Practice Location | |||||||||
| Address1: | 3000 ARLINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436142595 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193833888 | ||||||||
| FaxNumber: | 4193832860 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2006 | ||||||||
| LastUpdateDate: | 01/02/2018 | ||||||||
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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 | 35-07-4098 | OH | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000372959 | 01 | OH | ANTHEM | OTHER | 810547599032 | 05 | OH | MEDICAID | 727203 | 01 | OH | BCHP | OTHER | 000000271442 | 01 | OH | ANTHEM | OTHER | 4443886 | 05 | MI | MEDICAID | 2050855 | 05 | OH | MEDICAID |