Basic Information
| Provider Information | |||||||||
| NPI: | 1366694606 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KREMER PRILL | ||||||||
| FirstName: | MARNIE | ||||||||
| MiddleName: | JO | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 471 N. OLD NEWPORT #302 | ||||||||
| Address2: | |||||||||
| City: | NEWPORT BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926334244 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9496453534 | ||||||||
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| Practice Location | |||||||||
| Address1: | ONE HOAG DRIVE | ||||||||
| Address2: | |||||||||
| City: | NEWPORT BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926634162 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9496453534 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2008 | ||||||||
| LastUpdateDate: | 01/14/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | A109358 | CA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 1366694606 | 05 | CA | MEDICAID | 00A10935800 | 01 | CA | BCBS OF CA | OTHER |