Basic Information
| Provider Information | |||||||||
| NPI: | 1508473588 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MARATHON HEALTH LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20 WINOOSKI FALLS WAY | ||||||||
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| City: | WINOOSKI | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054042228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8028570400 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2257 N BAYLEN ST | ||||||||
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| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325011703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8505951949 | ||||||||
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| ProviderEnumerationDate: | 09/24/2020 | ||||||||
| LastUpdateDate: | 09/24/2020 | ||||||||
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| AuthorizedOfficialLastName: | FORD | ||||||||
| AuthorizedOfficialFirstName: | JERRY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8028570400 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MARATHON HEALTH LLC | ||||||||
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| NPICertificationDate: | 09/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.