Basic Information
| Provider Information | |||||||||
| NPI: | 1558352559 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EIDENBERG | ||||||||
| FirstName: | MARSHALL | ||||||||
| MiddleName: | EDWARD | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2220 CANTERBURY DR | ||||||||
| Address2: | |||||||||
| City: | HAYS | ||||||||
| State: | KS | ||||||||
| PostalCode: | 676012370 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7856235555 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2220 CANTERBURY DR | ||||||||
| Address2: | |||||||||
| City: | HAYS | ||||||||
| State: | KS | ||||||||
| PostalCode: | 676012370 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7856235555 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2005 | ||||||||
| LastUpdateDate: | 03/08/2016 | ||||||||
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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 | 05-32944 | KS | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200548360A | 05 | KS | MEDICAID |