Basic Information
| Provider Information | |||||||||
| NPI: | 1548262702 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEWALD | ||||||||
| FirstName: | MARILYNN | ||||||||
| MiddleName: | S. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 CEDAR ST | ||||||||
| Address2: | |||||||||
| City: | HOUGHTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 499311978 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9064871710 | ||||||||
| FaxNumber: | 9064879421 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 CEDAR ST | ||||||||
| Address2: | |||||||||
| City: | HOUGHTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 499311978 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9064871710 | ||||||||
| FaxNumber: | 9064879421 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2005 | ||||||||
| LastUpdateDate: | 01/16/2015 | ||||||||
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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 | 207Q00000X | 4301056759 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 233857 | 01 | MI | RHC MEDICARE NUMBER | OTHER | 4301056759 | 01 | MI | MI LICENSE NUMBER | OTHER | BD2018605 | 01 | MI | DEA NUMBER | OTHER | 2668377 | 05 | MI | MEDICAID |